Columbia  (Bnitieri^ftj) 

intljeCitpoflmgork 

CoUegc  of  ^f)j>£iicians!  anb  burgeons! 
Hibrarp 


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DISEASES 


OF  THE 


RECTUM  AND  ANUS 


Designed  for  Students  and  Practitioners 

OF  Medicine 


BY 


SAMUEL  GOODWIN  GANT,  M.D.,  LL.D. 

PuoPESSOR  OP  Rectal  and  Anal  Surgery  at  the  New  York  Post-graduate  Medical  School  and  Hospitaij 

Attending  Surgeon  for  Rectal  and  Anal  Diseases  to  the  New  York  Post-Graduate  Hospital; 

Newport  Uospital  and  New  York  Infant  Asylum  and  St.  Mary's  Hospital,  Jamaica,  Eto. 


tbird  Edition,  Revised  and  Enlarged 


With  Thirty-Seven  Full-Page  Plates,  Twenty  of  Which  are  in 

Colors,  and  Two  Hundred  and  Twelve  Smaller 

Engravings  and  Half-tones 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  PUBLISHERS 

IQTO 


COPYRIGHT,  1902 
COPYRIGHT,  1905 


F.    A.    DAVIS   COMPANY 
[Registered  at  Stationers'  Hall,  London,  Eng. 


Press  of    F.   A.    Davis    Company 

1914-16   Cherry  Street 

Philadelphia,  Pa. 


4> 

-J 


C5^ 

>■  ■ 
CO 


THIS   WORK 


AFFECTIONATELY    DEDICATED 

TO  MY 

INSTRUCTOR,    FRIEND    AND    COLLEAGUE, 

D,   B.   St.   JOHN    ROOSA,   M.D.,   LL.D., 

FOUNDER    AND    PRESIDENT    OF    THE    FIRST 
POST-GRADUATE  SCHOOL  OF  MEDICINE. 


PREFACE  TO  THIRD  EDITION. 


The  preparation  of  the  third  edition  of  this  work  has  neces- 
sitated a  careful  revision  of  the  second  edition ;  typographical 
errors  appearing  in  the  latter  have  been  corrected,  and  such 
changes  and  additions  as  were  found  necessary  have  been  made. 
This  edition  includes  one  new  chapter,  viz. :  "Local  Anesthesia 
in  the  Treatment  of  Diseases  of  the  Sigmoid,  Rectum,  and  Anus," 
which  the  author  has  been  encouraged  to  add  because  of  the 
excellent  results  he  has  obtained  in  the  radical  treatment  of  these 
affections  under  local  anesthesia  in  the  office,  patient's  home,  and 
dispensary.  , 

The  author  desires  to  express  his  deep  obligations  to  Dr. 
Benjamin  E.  Dolphin  for  his  valuable  assistance,  and  to  the 
F.  A.  Davis  Company  for  the  many  courtesies  extended  during 
the  preparation  of  this  work. 

S.  G.  G. 

43  W.  FrFTY-SECOND  Street, 
New  Yoek  City. 


(V) 


PREFACE  TO  SECOND  EDITION 


The  advances  made  in  the  domain  of  rectal  surgery 
since  the  appearance  of  the  first  edition  of  this  work  have 
necessitated  a  complete  revision  and  the  addition  of  much  new 
material.  The  chapters  on  "Cancer"  and  "Colostomy,"  which 
in  the  first  edition  were  written  by  Mr.  Herbert  Allingham, 
have  been  entirely  rewritten  and  considerably  extended  in 
the  present  edition  by  the  author. 

To  render  the  volume  more  worthy  of  the  title  it  bears, 
three  entirely  new  chapters  have  been  prepared,  namely: 
"Diseases,  Injuries,  and  Tumors  of  the  Coccyx" ;  "Venereal 
Diseases  of  the  Ano-rectal  Region";  and  "Recto-colonic 
Enteroliths  and  Concretions." 

In  order  to  more  thoroughly  elucidate  the  text,  many 
new  and  original  illustrations  have  been  added  to  the  already 
large  number  prepared  for  the  first  edition.  These  additions 
comprise  five  full-page  colored  plates,  seventeen  full-page 
black-and-white  plates,  and  one  hundred  and  one  smaller  en- 
gravings and  half-tones.  It  will,  therefore,  readily  be  seen  that 
the  present  volume  is  practically  a  new  work. 

My  thanks  are  due  to  my  colleague,  Prof.  Henry  T. 
Brooks,  of  the  New  York  Post-graduate  Medical  School,  for 
writing  the  section  on  "Examination  of  the  Feces,"  for  cor- 
recting my  manuscript,  and  for  seeing  the  pages  through  the 
press;  to  Dr.  Bertram  H.  Buxton,  of  Cornell  Medical  College, 
for  making  the  excellent  photomicrographs;   to  my  assistants, 

Dr.  Kenneth  Keath  McAlpin  and  Dr.  Arthur  Landsman,  for 

(vii) 


Viii  PREFACE  TO  SECOND  EDITION 

valuable  assistance  in  consulting  literature ;  to  Mr.  R.  J. 
Hopkins  and  Mr.  Herbert  B.  Reissman,  artists,  for  many  of  the 
drawings  to  be  seen  throughout  the  work;  and  last,  but  not 
least,  to  Dr.  B.  E.  Dolphin  for  unselfishly  aiding  me  in  many 
ways.  I  desire  to  especially  thank  my  publishers,  F.  A.  Davis 
Company,  for  their  courtesy,  Hberality  in  regard  to  both  illus- 
trations and  letter-press,  and  their  hearty  co-operation  at  every 
stage  of  the  work. 

In  conclusion,  I  ask  the  privilege  to  assure  both  the 
medical  press  and  the  profession  at  large  of  my  grateful 
appreciation  of  the  generous  and  cordial  reception  granted  by 
them  to  the  first  edition  of  this  book.  I  trust  this,  the  second, 
edition  may  merit  a  continuance  of  their  favor. 

S.  G.  G. 

43  West  Fifty-secoxd  Street. 


PREFACE  TO  FIRST  EDITION 


This  treatise  is  the  result  of  an  effort  to  give  to  prac- 
titioners and  students  of  medicine  a  concise,  yet  practical, 
work.  I  have  not  attempted  to  give  a  detailed  discussion  of 
theories  and  antiquated  views  of  unrecognized  value.  Of 
recent  years  so  much  has  been  written  upon  "Asepsis  and  Anti- 
sepsis" and  "Rectal  Reflexes"  that  I  have  deemed  it  best  not 
to  devote  separate  chapters  to  these  subjects,  but  have  given 
them  sufficient  attention  throughout  the  entire  work.  Two 
chapters  have  been  written  that  are  new  in  a  work  of  this  kind : 
one  on  "Railroading  as  an  Etiologic  Factor  in  Rectal  Diseases" 
and  one  on  "Auto-intoxication  from  the  Intestinal  Canal."  I 
have  given  these  subjects  distinct  chapters,  for  I  am  sure  that 
their  importance  has  been  very  much  underrated  by  writers 
generally. 

In  the  case  of  words  in  which  a  diphthong  is  employed  I 
have  adopted  the  new  orthography.  For  example,  the  words 
hcemorrhoids,  fences,  diarrhoea,  etc.,  are  spelled  thus :  hemorrhoids, 
feces,  diarrhea,  etc. 

In  order  to  present  a  comprehensive  treatise  I  have  made 
frequent  reference  to  the  standard  works  on  diseases  of  the 
rectum  and  anus  and  to  reprints  and  monographs  too  numer- 
ous to  mention.  Among  the  text-books  which  I  have  consulted 
I  desire  to  mention  the  following:  Allingham,  Mathews, 
Cripps,  Kelsey,  Cooper  and  Edwards,  Van  Buren,  Ashton, 
Curling,    Ball,    Quain,    Henry    Smith,    and    Bodenhamer    on 

hemorrhoidal  disease.     I  have,  in  each  instance,   endeavored 

(ix) 


X  PREFACE  TO  FIRST  EDITION 

to  give  proper  credit  to  authors,  and  if  I  have  failed  in  a  single 
case  it  lias  been  unintentional. 

I  was  fortunate,  indeed,  in  getting  Mr.  Herbert  William 
AUingham,  of  St.  Mark's  Hospital,  London,  to  write  two 
chapters  on  "Cancer"  and  "Colostomy,"  for  I  doubt  if  there 
is  any  man  living  more  capable  of  dealing  with  these  im- 
portant subjects  than  he. 

I  wish  also  to  acknowledge  my  obligations  to  Dr.  J.  C. 
Stewart  for  valuable  assistance  rendered  in  perfecting  the 
many  original  diagrams  and  drawings  seen  throughout  the 
work;  and  to  my  friends,  Drs.  W.  F.  Kuhn  and  Daniel 
Morton,  for  correcting  my  manuscript.  To  my  publishers, 
F.  A.  Davis  Company,  I  wish  to  express  my  gratitude  for 
the  many  courtesies  received.  To  the  Burk  &  McFetridge 
Company,  who  made  the  many  beautiful  chromolithographic 
plates,  I  will  only  say  that  the  excellency  of  their  work  has 
surpassed  by  far  my  most  sanguine  expectations.  Trusting 
that  my  labors  may  prove  to  be  of  some  practical  value  to 
the  profession,  I  respectfully  submit  it  for  their  perusal. 

S.  G.  G. 

Kansas  City,  Mo. 


TABLE  OF  CONTENTS 


CHAPTER  I.  PAGE 

Introduction    1 

CHAPTER  11. 

Anatomy  and  Physiolocy  3 

The  Large  Intestine    3 

The  Sigmoid  Colon    6 

The  Rectum     8 

The  Arteries  of  the  R.ectum 14 

The  Veins  of  the  Rectum 14 

The  Nerves  of  tlie  Rectum 15 

The  LjTiiphatics  of  the  Rectum 16 

The  Muscles  of  the  Rectum 16 

The  Anus    18 

The  Perirectal  Spaces    18 

The  Ischio-rectal  Eossse   19 

The  "Rectal  A'^alves"    (lolds) 19 

Physiology 29 

Literature     32 

CHAPTER  III. 

Symptomatology    (Semeiology)    34 

Gant's  Card-Index  History  Chart 40 

CHAPTER  IV. 

Examination    41 

Preparation 41 

Instruments   42 

Position  of  the  Patient 48 

Anesthesia    48 

Examination  of  Eeces  52 

Character  of  Dejecta  in  Certain  Affections 62 

CHAPTER  V. 

Congenital  Malformations 73 

Classification 73 

Symptoms     78 

Diagnosis    79 

Prognosis    81 

Synopsis  of  Cases 82 

Treatment    83 

Literature 88 

CHAPTER  VI. 

Constipation     90 

Etiology    90 

Symptoms     ., 92 

Treatment     94 

Non-medicinal  Treatment    95 

Surgical  Treatment    102 

Gant's  Clamp  Operation    lOi 

(xi) 


xii  TABLE  OF  CONTEXTS 

CHAPTER  VII.  PAGE 

Fecal  Impactioj?  (Coprostasis)    108 

Etiology  and  Pathology  108 

Symptoms     109 

Diagnosis    110 

Prognosis    112 

Treatment 112 

Synopsis  of  Cases 116 


CHAPTEPv  VIII. 

Atjto-infection  and  Auto-intoxication  fpvOM  the  Intestinal  Canal.  120 

The  Circulatory   System    125 

The  Kespiratory  System   126 

The  Skin     126 

The  Nervous  System    126 

The  Bacillus  Coli  Communis    129 

Treatment    136 

Literature     139 


CHAPTER  IX. 

Cheonic  DiaPvPvHEa   140 

Symptoms   and  Diagnosis 143 

Treatment    144 

Illustrative    Cases    147 

CHAPTER  X. 

Diseases,  InjuPvIes,  and  Tumors  of  the  Coccyx 149 

Malformations    (Abnormalities)     149 

The  Coccygeal  Body  and  its  Diseases 152 

Coccygodjmia     153 

Fractures,  Dislocations,  Injuries,  and  Necrosis  of  the  Coccyx 159 

Sacro-coccygeal  Tumors  and  Cysts 161 

Syphilis  and  Tuberculosis  of  the  Coccyx 166 

Synopsis  of  Cases    168 

Illustrative  Case 172 

Literature    172 


CHAPTER  XL 

Venereal  Diseases  of  the  Ano-rectal  Region 175 

Gonorrhea    (Clap)    175 

Chancroids   (Soft  Chancres) 178 

Syphilis   179 

Condylomata    (Venereal    Warts,    Vegetations,    ^iucous    Patches, 

Papillomata,   Dermophymata   Venerea) 182 

Venereal  Diseases  Caused  by  Sodomy  and  Rectal  Onanism 187 

Illustrative   Case    187 

Literature    188 


CHAPTER  XII. 

Pruritus  Am  (Itching  of  the  Anus,  Itching  Piles) 190 

Etiology   and   Pathology 190 

Symptoms  and  Diagnosis 194 


TABLE  OF  CONTENTS  xiii 

CHAPTER  XIII.  PAGE 

PEtmiTus  Ani  (Continued) 197 

Treatment    197 

Surgical  Treatment   205 

Illustrative   Case    208 

Literature    206 


CHAPTER  XIV. 

Pkoctitis    (Rectitis,   Catakkh   of   the   Rectum)    and    Membranous 

colo-pkoctitis    207 

Acute  Proctitis   207 

Chronic  Proctitis    210 

Membranous  Colo-proctitis   216 

Literature    222 


CHAPTER  XV. 

Peripkoctitis  (Ano-rectal,  or  Ischio-rectae,  Abscess) 224 

Symptoms     226 

Diagnosis    228 

Prognosis    228 

Treatment 229 

Literature     232 


CHAPTER  XVI. 

Ano-rectal  Fistula    233 

History    233 

Etiology  and  Pathology 236 

Varieties 238 


CHAPTER  XVII. 

Ano-rectal  Fistula   (Cnntlnued) 243 

Symptoms     243 

Diagnosis    245 

Prognosis    248 


CHAPTER  XVIII. 

Ano-rectal  Fistula   (Continued) 2.50 

Palliative   Treatment    250 

Operative   Treatment    250 

After-treatment    267 

Illustrative   Cases    270 

Literature 284,  285 


CHAPTER  XIX. 

The  Relation  of  Phthisis  Pulmonalis  to  Fistula  in  Ano 275 

Differential  Diagnosis   278 

Treatment    ....".. 280 

Palliative  Treatment    280 

Operative   Treatment 281 

Illustrative  Cases 283 

Literature    284 


xiv  TABLE  OF  CONTENTS 

CHAPTER  XX.  PAGE 

Fecal  Ixco>'tixexce    286 

Etiology  and  Pathology 286 

Symptoms   and  Diagnosis 288 

Prognosis    289 

Treatment    , 290 

Illustrative   Case    , 292 

Literature    293 


CHAPTER  XXL 
Anal    Fissure,    ok    Painful    Ulcer    (Irritable    Ulcer,    Sphincter- 

ALGIA) 294 

History   294 

Etiology  and  Pathology   295 

Symptoms     300 

Diagnosis    303 

Prognosis    306 


CHAPTER  XXII. 

Anal  Fissure  (Continued) 307 

Palliative   Treatment    307 

Operative  Treatment 312 

Illustrative  Cases   316 

Literature    317 


CHAPTER  XXIII. 

Non-malignant  Ulceration  and  Esthiomene 319 

Etiology   and  Pathology 319 

Symptoms     331 

Diagnosis    334 

Prognosis    334 

Treatment 335 

Palliative   Treatment    335 

Surgical  Treatment   338 

Illustrative  Cases 343 

Literature    : 346 

Esthiomene     339 

Etiology  and  Pathology 339 

Symptoms 341 

Diagnosis    342 

Treatment    342 

Literature 347 


CHAPTER  XXIV. 

NoN- malignant   Stricture    348 

Etiology  and  Pathology 349 

Pathology     357 

Symptoms     358 

Diagnosis    362 

Prognosis    365 

Treatment    366 

Palliative   Treatment    367 

OperatiA'e   Treatment    367 

Illustrative   Cases    ■ 377 

Literature    381 


TABLE  OF  CONTENTS  XV 

CHAPTER  XXV.  page 

Pbolapse  (Procidentia  Recti,  Prolapsus  Ani) 382 

l^tiology fl 

Pathology     fl 

Classification   ^°^ 

Diagnosis f^' 

Symptoms     ^f 

Prognosis  ^^^ 


Treatment 


390 


Palliative  Treatment ^90 

Surgical  Treatment   ^^^ 

Operations  for  Reduction  of  the  Caliber  or  Length  of  the  Rectum 

and  Shortening  of  the  Sphincter-muscle 394 

Fixation  of  the  Bowel  to  the  Sacro-coccygeal  Curve 397 

Amputation,  Excision,  and  Resection 400 

Illustrative   Cases ^^^ 

Literature    ^^' 


CHAPTER  XXVI. 

External  and  Internal  Hemorrhoids  (Piles) 408 

History   ^^8 

Classification   409 

Etiology 410 

Pathology     ^^^ 


CHAPTER  XXVII. 

External  Hemorrhoids    (Piles) 418 

Symptoms     418 

Diagnosis    ^j^ 

Treatment    '*^^ 

Illustrative   Cases    422 


CHAPTER  XXVIII. 

Internal  Hemorrhoids   (Piles) 424 

Symptoms     424 

Diagnosis    '*'^" 

Prognosis    ^"^° 


CHAPTER  XXIX. 

Internal  Hemorrhoids   (Continued) 429 

Palliative   Treatment    430 

Surgical  Treatment   433 

Illustrative   Cases    468 

Literature    471 


CHAPTER  XXX. 


Hemorrhage 


473 


Etiology  and  Pathology 473 

Symptoms  and  Diagnosis 475 

Methods  of  Arresting  Hemorrhage 476 


xvi  TABLE  OF  CONTENTS 

CHAPTER  XXXI.  page 

Non-malignant  Tumors  (Rectal  Polyps) 483 

Symptoms     495 

Diagnosis    496 

Prognosis    497 

Treatment 497 

Illustrative   Cases 499 

Literature 501 


CHAPTER  XXXII. 

Malignant  Tumors  (CARCiNOiiA  [True  Cancer]  and  SARCOiiA) 502 

History    502 

Classification   505 

Carcinoma,  Etiology   506 

Pathology     510 

Sarcoma,  Etiology   521 

Classification    521 

Symptoms     524 

Diagnosis    528 

Prognosis    533 


CHAPTER  XXXITI. 

Malignant  Tumors   (Vontinued) 534 

Palliative  Treatment    534 

Surgical  Palliative  Treatment   539 

Radical  Treatment    541 

Proctectomy    (Excision)    543 

Complications  and  Sequels 573 

Permanent  Results    575 

Causes  oi  Death 577 

Literature    577 


CHAPTER  XXXIV. 

Colostomy   (Colotomy,  Artificial  Anus) 582 

Classification   586 

Left  Inguinal  (Iliac)  Colostomy  (Sigmoidostomy) 589 

Transverse   Colostomy    598 

Right   Inguinal   Colostomy 599 

Left  Lumber  Colostomy 599 

Right  Lumber  Colostomy 600 

After-treatment    600 

General  Remarks  on  Colostomy   601 

Complications  and  Sequels 615 

Literature    617 


CHAPTER  XXXV. 

Closure  of  Artificial  Anus  and  Fecal  Fistula 619 

Methods  of  Closing  an  Artificial  Anus 620 

Methods  of  Closing  Fecal  Fistula    623 

Literature     624 


TABLE  OF  CONTENTS  xvii 

CHAPTER  XXXVI.  page 

Netjkalgta  (Ner^ti-ache)  and  Hyperesthesia  (Hysterical  Rectum)  .  t)'25 

Etiology   and  Pathology 625 

Symptoms     626 

Diagnosis    627 

Prognosis    627 

Treatment     628 

Hyperesthesia    (Hysterical  Rectum) 631 

Symptoms     63 1 

.Diagnosis    631 

Treatment    632 

Illustrative  Cases 632 

Literature    634 


CHAPTER  XXXVII. 

Enteroliths  and  Concretions 635 

Symptoms     640 

Diagnosis    641 

Treatment    641 

Synopsis   of  Cases 642 

Literature    643 


CHAPTER  XXXVIII. 

Foreign  Bodies,  Wounds,  and  Injuries 645 

Symptoms     648 

Treatment    649 

Illustrative   Case    650 

Literature     652 


CHAPTER  XXXIX. 

Sodomy  (Pederasty)  and  Rectal  Onanism  (Rectal  Masturbation)  .  653 

Rectal   Onanism    658 

Literature    658 


CHAPTER  XL. 

Railroading  as  an  Etiologic  Factor  in  Rectal  Disease 660 

Irregularities  in  Living 662 

Results  of  Constipation 665 

Erect   Position 666 

Irregular,   Jarring   Motion 666 

Synopsis  of  Cases    669 

CHAPTER   XLL 

Local  Anesthesia  in   the  Treatment  of  Diseases  of  the  Sigmoid, 

Rectum  and  Anus 671 

Local  Anesthetics 672 

Ether  Spray,  Ethyl  Chloride,  Liquid  Air —  672 

Cataphoresis,   ( Electricity )  672 

Cocaine  and  Eucaine 672 

Sterile  Water G74 

Index .- 681 


LIST  OF  TABLES 


TABLE  PAGE 

I.  Synopsis  of   Eight  Cases  of  Congenital  Malformation  of  the  Eec- 

tum  and  Anns  Treated  by  the  Author 82 

II.  Congenital  Malformations  (Cripps) 83 

III.  Congenital  Malformations  (Bodenhamer)     83 

IV.  Two   Hundred   and   Fifty  Cases  of    Constipation  Treated  by  the 

Non-medicinal  Method     101 

V.  Differential  Diagnosis  between  Fecal  Impaction  and  Carcinoma  of 

the  Large  Intestine Ill 

VI.  Synopsis  of   Forty-six   Cases  of   Fecal   Impaction  Treated  by  the 

Author     116-119 

VII.  Synopsis  of  Thirty-seven  Cases  of  Diseases,  Injuries,  and   Tumors 

of  the  Coccyx  Treated  by  the  Author 168-171 

VIII.  Analytic  Table  of  Diseases  of  the  Coccyx 171 

IX.  Differential  Diagnosis  between  Tuberculous  and  Non-tuberculous 

Fistula 278-279 

X.  Diiierential  Diagnosis  of   Fissure  and  Ulceration 305 

XI.  Cripps's  Table  of  Stricture 352 

XII.  Author's   Table  of   Stricture 352 

XIII.  Differential     Diagnosis    between    Non-malignant   and    Malignant 

Stricture 364-365 

XIV.  Differential    Diagnosis   between   Hemorrhoids,   Procidentia  Eecti, 

and   Polyps 427 

XV.  Statistics  of  Cancer 503 

XVI.  Statistics  of   Ano-rectal  Cancer 504 

XVII.  Statistics  of   Intestinal  Cancer 504 

XVIII.  Location  of  Cancerous  Tumors  in  One  Hundred  Cases  Examined  by 

the  Author 511 

XIX.  Frequency  of   Intestinal  Sarcoma  in   Different   Decades 521 

XX.  Location  of   Intestinal  Sarcoma  in   Thirty-seven   Cases     521 

XXI.  Statistics  of   Operability  of  Rectal  Cancer 564 

XXII.  Vogel's  Modification  of   Kronlein's  Table  on  the  Operability  and 

IMortality  of   Kraske's  Operation 564 

XXIII.  Statistics  of   Incontinence  following  Proctectomy 575 

XXIV.  Permanent   Eesults   Obtained   from    Rectal    Excision  by  Leading 

Operators  of   Europe 576 

XXV.  Synopsis  of  Fifty-four  Cases  of  Enteroliths  and  Intestinal  Concre- 
tions Collected   by  the  Author 642 

XXVI.  Tardieu's  Statistics  Regarding  the  Ages  and  Occupations  of  Ped- 
erasts     654 

XXVII.  Author's  Analysis  of   One  Hundred  and  Seventy  Thousand   Rail- 
way Cases 667 

XXVIII.  Synopsis  of   Thirty  Cases  of   Rectal  and  Anal  Diseases  Treated  by 
the  Author  at  the  Kansas  City,  Fort  Scott  &  Memphis  Railway 

Hospital,  from  January  1,  1893,  to  January  1,  1894 669 

XXIX.  Table  of  Three  Hundred  and  Twenty  Cases  of  Rectal  and  Anal 
Affections  Radically  Operated  upon  by  the  Author  in  the  Office, 
Patient's  Home,  Dispensary  or  Hospital  Under  Sterile  Water 
Anesthesia 676 

(xviii) 


LIST  OF  ILLUSTRATIVE  CASES 


CASE                                                                                                             ^^<^^ 
I.  Chronic  Diarrhea  Caused  by  Ulceration 147 

II.  Chronic  Diarrhea  Caused  by  Rectal  Polyp 148 

III.  Entire  Absence  of  the  Coccyx  in  an  Adult  (Congenital) 172 

IV.  Gummata  of  the  Rectum 187 

V.  Pruritus  Ani  (Aggravated  Case) 206 

VI.  Complex   Fistula   with  Thirty-seven   Openings   upon   the   But- 
tocks, Eight  in  the  Vulva,  and  Three  in  the  Rectum 270 

VII.  Horseshoe   Fistula    271 

VIII.  Blind   Internal   Fistula 274 

IX.  Tubercular  Fistula  (Ligature  Operation) 283 

X.  Tubercular  Fistula   (Division  Operation) 284 

XL  Incontinence  Due  to  Rupture  of  the  Sphincter-muscle 292 

XII.  Painful  Ulcer  Caused  by  Constipation 316 

XIII.  Painful  Ulcer  with  Bladder  Complications 316 

XIV.  Painful  Ulcer  within  External  Pile 317 

XV.  Ulceration  of  the  Rectum   (Temporary  Colostomy)  ;   Artificial 

Anus,  Closed  more  than  Three  Years  Later 343 

XVI.  Ulceration  of  the  Rectum  (Curettage  and  Incision) 344 

XVII.  Ulceration  of  the  Rectum  (Cauterization  with  Nitric  Acid) 345 

XVIII.  Tubercular   Ulceration    (Curettage) 345 

XIX.  Stricture  Due  to  Muscular  Band   (Internal  Proctotomy) 377 

XX.  Stricture  of  the  Rectum   (Posterior  Proctotomy) 377 

XXI.  Stricture  of  the  Rectum,  with  Almost  Complete  Obstruction. . .   378 
XXII.  Stricture  of  the  Rectum  (External  Proctotomy) 380 

XXIII.  Stricture  Due  to  Fibrous  Band  (Gradual  Divulsion) 380 

XXIV.  Prolapse  Due  to  Summer  Diarrhea  (Cauterization) 404 

XXV.  Extensive  Prolapse  of  All  the  Rectal  Coats 405 

XXVI.  Extensive  Prolapse   (Excision) 406 

XXVII.  Dwarfed  Child  Suffering  from  Prolapse 406 

(xix) 


XX  LIST  OF  ILLUSTRATIVE  CASES 

CASE  .  PAGE 

XXVIII.  External  Hemorrhoids  (Thromboti3  Variety) 422 

XXIX.  External  Hemorrhoids  (Thrombotic  Variety) 422 

XXX.  External  Hemorrhoids    (Cutaneous  Variety) 422 

XXXI.  External  Hemorrhoids  Complicated  with  Fissure 423 

XXXII.  Internal  Hemorrhoids  Treated  by  the  Injection  Method 468 

XXXIII.  Internal  Hemorrhoids   (Clamp-and-Cautery  Operation) 470 

XXXIV.  Internal  Hemorrhoids  Complicated  with  Ulceration   (Ligature 

Operation)    470 

XXXV.  Polyp    Weighing    Four    Ounces     (One    Hundred    and    Twenty 

Grams)  Removed  by  the  Ligature  Operation 499 

XXXVI.  Polyps  in  a  Child  Three  Years  of  Age.    Removed  by  Torsion.  .  500 

XXXVII.  Large  Fibrous  Polyp  of  Several  Years'  Standing 500 

XXXVIII.  Adenoid  Polyps.    Removed  by  Clamp  and  Cautery 500 

XXXIX.  Neuralgia  of  the  Rectum 632 

XL.  Neuralgia  Due  to  Scar-tissue .  633 

XLI.  Neuralgia  Due  to  a  Dislocated  Coccyx 633 

XLII.  Hyperesthesia  of  the  Rectum 634 

XLIII.  Stick  in  the  Rectum.    Death  from  Peritonitis 650 


LIST  OF  PLATES 


PLATE  FACING   PAGB 

I.  Congenital  Syphilis  of  the  Anus   (colored) Frontispiece 

II.  Rectum  Injected  with  Paraffin,  Showing  Position  of  Sigmoid 
and  Relation  of  the  Peritoneum  to  the  Sacrum,  Rectum,  and 
Bladder    10 

III.  Levatores   Ani  as   Seen  from  Above,  Showing  how  they   Pass 

Around  the  Rectum  (colored) 17 

IV.  Levatores  Ani,  Side- View,  Showing  their  Relation  to  the  Rec- 

tum  (colored)    . l^ 

V.  Rectum,  Cut  Open,  Showing  Two  "Rectal  Valves" 25 

VI.  Paraffin     Cast,     Showing     Indentations     Made     by     Houston's 

"Valves" •  ■  •  '^-o 

VII.  Transverse  Section  through  a  "Rectal  Valve" 26 

yill.  The  "Rectal  Valve,"  Houston's,  Showing  Tip 28 

IX.  Gant's  "Valvotomy"  Instruments   103 

X.  Gant's  Operation  of  "Valvotomy" 104 

XI.  Infectious  Condj'lomata  Lata  Involving  the  Anus,  Penis,  and  In- 

terdigital  Spaces   (colored)    i^l 

XII.  Non-syphilitic  Condylomata   Acuminata    (colored) 183 

XIII.  Condyloma   (Acuminatiun)    Ani   184 

XIV.  Medullary    Adenocarcinoma     and    .Proctitis     as     they     Appear 

throvigh  the  Proctoscope   (colored) 212 

XV.  Case  of  Recto-vesical  Fistula,  Showing  Result  of  Extravasation 

of  Urine  into  Scrotum  and  Penis   (colored) 241 

XVI.  Complete  Fistula  in  Ano  with  Division  Operation  for  same  (col- 
ored)       256 

XVII.  Painful  Ulcer  of  the  Anus   (colored) 294 

XVIII.  Ulceration  of  the  Rectum  and  Polypoid-like  Sentinel  Teats  (col- 
ored)      ^1^ 

XIX.  Primary  Ano-rectal  Tuberculosis   (colored) 325 

XX.  Diagrammatic  Drawing  of  Rectal  Stricture   (colored) 357 

XXI.  Extensive  Complete  Procidentia  Recti   (colored) 382 

XXII.  Protruded  Internal  Hemorrhoids   (colored) 408 

(xxi) 


xxii  LIST  OF  PLATES 

PLATE  FACING   PAGE 

XXIII.  Showing  the   Vascular   Supply   of   Internal   Hemorrhoids    (col- 

ored)   413 

XXIV.  Microscopic  Appearance  of  Internal  Hemorrhoids 416 

XXV.  External  Thrombotic  Hemorrhoids   (colored) 418 

XXVI.  Gant's   Clamp   Adjusted   for   Excision   of   Protruding   Internal 

Hemorrhoids  (colored) 438 

XXVII.  Adenoma  of  the  Rectum   (Magnification,  8) 484 

XXVIII.  Adenoma  of  the  Rectum   (Magnification,  250) 486 

XXIX.  Epithelioma  of  the  Anus 502 

XXX.  Cylindric-Celled  Adenocarcinoma  of  the  Rectum 506 

XXXI.  Carcinoma  of  the  Rectum 514 

XXXII.  Metastatic  Deposit  in  Lymph-node  from  Colloid  Carcinoma  of 

the  Rectum   520 

XXXIII.  Sarcoma  of  the  Rectum 522 

XXXIV.  Fibrosarcoma  with  Multiple  Fistulas   (colored) 531 

y XXV.  Metastasis  in  Inguinal  Lymph-node 534 

XXXVI.  Artificial  Anus  in  Left  Inguinal  Region  (colored) 582 

XXXVII.  Case  of  Double  Procidentia  of  Part  of  Descending  Colon   and 

Kectum  (colored)   G16 


LIST  OF  ILLUSTRATIONS 


PIG.  PAGE 

1.  Reeto-colonic   Diverticulse    5 

2.  Sigmoid  Colon  and  its  Relation  to  the  Rectum 6 

3.  The   Rectum   and   Sigmoid,    Showing   Curves,    Mesentery,    Bladder,    and    Recto- 

vesical Fold  of  Peritoneum   8 

4.  Lateral  "View  of  Rectum,   Showing  Mesentery,   Direction  of  Blood-vessels,   and 

Peritoneum  Binding  the  Rectum  and  Sacrum  Together H 

5.  The  Rectum  Distended   26 

6.  Proctoscopic  View  of  "Valves"  in  an  Inflated  Rectum 27 

7.  Allison  Office  and  Operating  Table 42 

8.  Allison  Oflice  Instrument  Cabinet   43 

9.  The  Martin  Chair  for  the  Proctoscopy  Posture 44 

10.  Battery  and  Little  Wonder  Electric  Light 45 

11.  Little  Wonder  Electric  Light  in  Position 46 

12.  Gant's  Artificial  Light,  Table,  and  Irrigating  Apparatus 47 

13.  Gant's  Office  Speculum   48 

14.  Cook's  Trivalved  Operating  Speculum  49 

15.  Hinged   Speculum    50 

16.  Pratt's  Bivalved  Operating  Speculum   51 

17.  Mathews's  Rectal  Speculum  52 

18.  Sims's  Wire   Speculum    53 

19.  Kelly's  Colonoscope,  Proctoscope,  and  Anoscope  54 

20.  Kelly's  Proctoscope  with   Electric-Light  Attachment 55 

21.  Laws's   Proctoscope    56 

22.  Method  of  Using  Various  Instruments  through  the  Laws  Proctoscope 57 

23.  Pennington's  Proctoscope  58 

24.  Bodenhamer's  Proctoscope  iand  Reflecting  Mirror 59 

25.  Martin's  Proctoscope,  with  Obturator  in  Position 59 

26.  The  Exaggerated  Knee-Chest,  or  Mart.n,  Posture 60 

27.  Patient  Prepared  and  in  Position  for  Examination  or  Operation 61 

28.  Esmarch's  Chloroform-inhaler   62 

29.  Correct    Method    of    Digital    Examination    with    the    Patient    in    the    Lithotomy 

Posture    , 63 

30.  Rubber  Finger-stall  for  Rectal  Examination 64 

31.  Oxalate  of  Calcium,  Frequently  found  in  Diarrhea 65 

32.  Cholesterin   Crystals 66 

33.  Narrowing  of  the  Anus  without  Complete  Occlusion 74 

34.  Closure  of  the  Anus  by  Membranous  Tissue 75 

35.  Imperforate  Anus,  the  Rectum  Terminating  far  Above  in  a  Blind  Pouch 76 

36.  Imperforate  Anus,  the  Rectum  Opening  into  the  Vagina  77 

37.  Imperforate  Anus,  the  Rectum  Terminating  in  the  Urethra  78 

38.  Imperforate  Anus,  the  Rectum  Terminating  in  the  bladder  79 

39.  Imperforate  Anus,  the  Rectum  Opening  on  the  Surface  by  means  of  a  Fistulous 

Sinus  through  the  Penis 80 

40.  Imperforate  Rectum.     The  Anus  Natural,  but  the  Rectum  Obstructed  Above  it 

by   a   Membranous   Partition , 81 

41.  Showing  how  the  Uterus  may  Press  the  Rectum  back  Against  the  Bony  Struct- 

ures,  Causing  Partial  Occlusion  and  Constipation 91 

42.  A   Serviceable   Bed-pan   112 

43.  Barger's  Artificial  Defecator  and  Irrigator 113 

44.  Rectal  Scoop  for  the  Removal  of  Impacted  Feces 113 

45.  Modified  Kelly  Pad    114 

(xxiii) 


xxiv  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

46.  Diagrammatic  Drawing  Showing  Deviation  of  the  Coccyx  Anteriorly 150 

47.  Diagrammatic  Drawing  Showing  Deviation  of  the  Coccyx  Posteriorly 151 

48.  Gant's  Coccygeal   Scissors    158 

49.  Gant's  Operation  for  Coccygogectomy   159 

50.  Rubber    Glove    160 

51.  Sacro-coccygeal  Tumor  (Front   View) 162 

52.  Sacro-coccygeal  Tumor  (Rear  View)    163 

53.  Eczema  Marginatum   193 

54.  Gant's  Recto-colonic   Sprays    210 

55.  Hypertrophic  Proctitis,  Showing  Desquamated  Fatty  Epithelia,  Leucocytes,  Cal- 

cium-Oxalate  Crystals,  and  Bacteria  211 

56.  Kemp's  Rectal   Irrigator,   New   Model 216 

57.  Membranous   Colo-proctitis,   Showing  Membrane   Inclosing  Fatty  and   Granular 

Epithelia  and  Leucocytes    217 

58.  Symmetric  Ischio-rectal  Abscesses   229 

59.  Complete  and  Blind  Internal  Fistulae      234 

60.  Types  of  Complete  Fistula  235 

61.  Unusual  Types  of  Complete  Fistula    235 

62.  Unusual  Types  of  Blind  Internal  Fistula 235 

63.  Common  Types  of  Blind  Internal  Fistula 235 

64.  Blind  External  and  Complete  Internal  Fistulae 236 

65.  Complete  External  and  Recto-vaginal  Fi.-f nlse      237 

66.  Complex  Horseshoe  Fistula  with  Six  Openings  on  the  Surface 238 

67.  Horseshoe    Fistula    239 

68.  Complex  Horseshoe  Fistula  with  Multiple  Openings  In  and  Outside  the  Rectum..  240 

69.  Recto-vesical  and  Recto-urethral  Fistulae      241 

70.  71,  and  72.     Ligature  Operation  for  Fistula  in  Ano 254 

73.  Allingham's  Elastic  Ligature  Carrier   255 

74.  Fistulatome   255 

75.  Right  Way  to  Cut  the  Sphincter  in  Operations  for  Fistula  in  Ano 257 

76.  Wrong  Way  to  Cut  the  Sphincter  in  Operations  for  Fistula  in  Ano 257 

77.  Gant's  Sets  of  Graduated  Probes  and  Grooved  Directors 258 

78.  Gorget   2;59 

79.  Allingham's  Scissors  and  Grooved  Director  259 

80.  Proper  Method  of  Using  Allingham's  Scissors  and  Director 260 

81.  Gant's  Angular  Grooved  Director  for  Blind  Internal  Fistula 261 

82.  Method  of  Using  Gant's  Angular  Grooved  Director,  First  Step 262 

83.  Second    Step    263 

84.  Third    Step     264 

85.  Simple  Horseshoe  Fistula  Before  Operation  265 

86.  Appearance  of  Wound  After  Operation 265 

87.  Complex  Horseshoe  Fistula  Before  Operation 266 

88.  Appearance   of   Wound    After   Operation,    the    Sphincter-Muscle    Being    cut   but 

Once    266 

89.  Small  Darmack  Gauze  Carrier  267 

90.  Appearance  of  Wounds  Three  Weeks  After  Operation  in  Case  of  Multiple  Fist- 

ulae    with   Extensive   Burrowing 271 

91.  Horseshoe  Fis*:ula  with  Multiple  Openings   272 

92.  Lines  of  Incisions  Showing  how  the  External  Sinuses  were  Made  to  Communi- 

cate with  Each  Other,  and  with  the  Rectum  and  the  Sphincters  Severed  but 
Once,  and  then  at  Right  Angle  273 

93.  Appearance  of  the   Anus   where   the   Sphincter  was   Cut  in   Three   Places   in   a 

Young  Woman  who  Recovered  Perfect  Control  of  the  Bowel  in  Six  Weeks...  287 

94.  Showing  Fissure  Caused  by  Tearing  and  Dragging  Downward  of  the  Semilunar 

Valves  and  the  Formation  of  the  Typic  "Sentinel  Pile" 299 

95.  Gant's  Large  Operating   Speculum    315 

96.  Primary  Tuberculosis  of  the  Rectum  and  Anus,  Showing  Tubercular  Deposits...  323 

97.  Primary  Tuberculosis  of  the  Skin  and  Mucous  Membrane  at  the  Anal  Outlet....  324 

98.  Lupus  of  the  Anus  in  Young  Boy   (Unusual) 325 

99.  Tuberculcsia  of  the  Mesenteric  Lymph-nodes 326 


LIST  OF  ILLUSTRATIONS  XXV 

FIG.  PAGE 

100.  Ulceration  of  the  Rectum  Caused  by  Diphtheritic  Inflammation 330 

101.  Kelsey 's  Rectal  Retractor  334 

102.  Sims's  Rectal  Irrigator  and  Draining-tube 336 

103.  Insufflator     336 

104.  Allingham's   Ointment   Applicator    337 

105.  Gant's  Recto-colonic  Ointment  Syringe   337 

106.  Esthiomene,  Vegetating  Variety  (Ano- vulvar  Region) 339 

107.  Diagrammatic  Drawing  of  Annular  Stricture   349 

108.  Diagrammatic  Drawing  of  Tubular  Stricture  349 

109.  Complete  Tubular  Stricture  of  the  Rectum  Due  to  Chronic  Proliferating  Stenos- 

Ing    Proctitis 355 

110.  Appearance  of  a  Cross-section  of  Strictured  Rectum 358 

111.  Correct  Method  of  Introducing  a  Rectal  Bougie 362 

112.  Bodenhamer's  Rectal   Explorer    363 

113.  Ideal  Anal  Dilators   368 

114.  Durham's  Rectal  Dilator   369 

115.  Whitehead's  Rectal   Dilator 370 

116.  Set  of  "Aloes"  Hard-Rubber  Bougies 371 

117.  Wales's  Soft-Rubber  Rectal  Bougies   372 

118.  Showing  Applicator  Passing  through  Left  Inguinal  Colostomy  Opening  and  Out 

at  the  Anus  to   Show  the  Direct  Line   Between  these   Points   and   also   the 
Method  of  Making  Topic  Applications  to  the  Rectum  from  Above 375 

119.  Appearance  of  Gut  Before  Removal 379 

120.  Artificial    Anus    One    Year   After    Operation,    Showing    Contraction    from    Scars 

Around  the  Opening,  which  Caused  Partial  Obstruction 380 

121.  Diagrammatic  Drawing  Showing  Prolapse  of  the  Rectum 382 

122.  Prolapse  of  the  Mucous  Membrane  (Partial  Procidentia) 383 

123.  Partial  Prolapse  in  a  Young  Man 384 

124.  Typic  Case  of  Extensive  Complete  Procidentia  Recti  in  Boy   Three  Years  Old 

(Congenital)    385 

125.  Typic  Case  of  Extensive  Complete  Procidentia  Recti  in  Boy  Three  Years  Old 386 

126.  Case  of  Complete  Procidentia  Recti  Complicated  by  Stricture  in  a  Woman 387 

127.  Prolapsus   Ani   Truss    392 

128.  Rectal    Plug 393 

129.  Gant's  Operation  for  Procidentia  Recti,     First  Step 395 

130.  Gant's  Operation  for  Procidentia  Recti.     Second   Step    395 

131.  Gant's  Operation  for  Procidentia  Recti.      Third    Step 396 

132.  Submucous  Operation  for  Procidentia  Recti 403 

133.  Le  Roy  Indestructible  Cautery   404 

134.  Dwarfed  Child  Suffering  from  Extensive  Prolapse  of  the  Rectum 405 

135.  Appearance  of  Dwarfed  Child  Eighteen  Months  After  Cure  of  Prolapse,   Show- 

ing the  Effect  of  Operation  and  Thyroid  Treatment 406 

136.  Cross-section   of   Internal   Hemorrhoids 414 

137.  Protruding   Internal   Hemorrhoids 415 

138.  Hemorrhoidal   Truss    433 

139.  Clover's    Crutch    434 

140.  Dilatation  of  the  Sphincter  Ani 435 

141.  Gant's   Hemorrhoidal   and   Tissue-forceps 436 

142.  Severing  the  Mucous  Membrane  from  the  Skin 437 

143.  Gant's  Pile,  Prolapse,  and  Polyp  Clamp 438 

144.  Improved  Paquelin  Cautery   439 

145.  Cauterizing   the    Stump 440 

146.  Gant's  Operating  Harness   (Back  and  Front  Views) 441 

147.  Smith's  Hemorrhoidal   Clamp    442 

148.  Cautery  Blow-pipe  for  Heating  Irons 443 

149.  Cautery   Irons    444 

150.  Mathews's    Pile-forceps    445 

151.  Thomas's   Curved   Tissue-forceps    445 

152.  Correct  Method  of  Ligating  Protruding  Internal  Hemorrhoids 447 

153    Earle's  Clamp-forceps 454 


XX vi  LIST  OF  ILLUSTRATIONS 

FIG.  '  PAG3 

154.  Gant's  Hemorrhoidal  and  Fistula  Syringe  458 

155.  Showing  Submucous  Ligation  of  Hemorrhoids 461 

156.  Pollock's  Hemorrhoidal  Crusher  464 

157.  Herbert  Allingham's  Pile-crusher   464 

158.  Appearance  of  Hemorrhoids  Before  Crushing  Operation    465 

159.  Appearance  of  Lower  Rectum  After  Crushing  Operation  for  Hemorrhoids 466 

160.  Drainage-tube  Wrapped  with   Gauze   477 

161.  Hollow  Vulcanite   Drainage-tube    477 

162.  Benton's  India-Rubber  Tampon  (Modified  by  Edwards) 478 

163.  Method  of  Packing  the  Rectum  with  Gant's  Modification  of  the  Darmack  Gauze 

Carrier   479 

164.  Gant's  Rectal  Evacuator   481 

165.  Pen   Sketch   of  Ano-vulvar   Fibromata 489 

166.  Embryonic  Tissue  Removed  from  Dermoid  Cyst  of  the  Sacrum 490 

167.  Epithelial  Tissue  Removed  from  a  Dermoid  Cyst  of  the  Sacrum 491 

168.  Elephantiasis  of  the  Ano-vulvar  Region 493 

169.  Adenoid    (Soft)    Polyp 494 

170.  Fibrous   (Hard)    Polyp    495 

171.  Removing  a  Polyp  with  the  Gant  Clamp 497 

172.  Gant's  Recto-colonic  Forceps  for  the  Removal  of  Polyps,   Foreign  Bodies,   and 

Dressings    498 

173.  Carcinoma  (Secondary)   of  Mesenteric  Glands 528 

174.  Showing  Amount  of  Bone  Removed  by  Different  Operations  in  Proctectomy 545 

175.  Inferior  Proctectomy.     Herbert  Allingham's  Preliminary  Incisions 551 

176.  Manner  of  Isolating  the  Bowel 552 

177.  Rectum  Freed  from  its  Surroundings,  Ready  to  be  Amputated 553 

178.  Showing  Bony  Integumentary  Flap  Held  Back  while  the   Growth  is   Removed 

and  an  End-to-End  Anastomosis  Is  Made  in  Superior  Proctectomy 557 

179.  Showing  Method  of  Amputating  the  Rectum  After  it  has  been  Freed  from  its 

Attachments  in   Superior  Proctectomy 558 

180.  Showing  Appearance  of  Wound  and  Location  of  the  Sacral  Anus  After  Superior 

Proctectomy    560 

181.  Proctectomy  by  the  Vaginal  Route   566 

182.  Proctectomy  by  the  Vaginal   Route    567 

183.  Rectal  Excision  by  the  Vaginal  Route   568 

184.  Jbhowing  Location  and  Length  of  Incision  in  Left  Inguinal  Colostomy 590 

185.  Longitudinal   Bands  and  Appendices  Epiploicae 591 

186.  No   Mesentery    591 

187.  Short   Mesentery    592 

188.  Long  Mesentery   592 

189.  Schematic  Drawing  Showing  Variable  Lengths  of  the  Mesentery  and  the  Dis- 

tance tne  Bowel  can  be  Pulled  Out  through  the  Incision 592 

190.  Manner  of  Placing  the  Mesenteric  futures  in  Left  Inguinal  Colostomy 594 

191.  Appearance  of  Wound  and  Bowel  at  the  Close  of  the  Operation  of  Left  Inguinal 

Colostomy  when  the  Gut  has  not  been  Opened 596 

192.  Mesentery   Made    faut    603 

193.  Artificial   Anus   Improperly   Made,    Showing   how   the   Feces   may    Escape   both 

through  the  Opening  in  the  Groin  and  into  the  Rectum 604 

194.  Artificial  Anus  Properly  Made  with  Spur,  Showing  the  Manner  in  which  All  the 

Feces  Find  an  Exit  through  the  Groin COS 

195.  Herbert  Allingham's  Colotomy   Clamp    606 

196.  Removal  of  Gut  with  the  Allingham  Clamp 606 

197.  Double-Barreled    Opening    607 

198.  Removal  of  Gut  Above  the  Skin  607 

199.  Forming    the    Spur 60S 

200.  Double  Procidentia  Following  Left  Inguinal  Colostomy  where  the  Excess  of  the 

Intestine  and  Mesentery  were  not  Amputated  During  the  Operation 613 

201.  Showing   how   Procidentia   Takes   Place   through    an   Artificial   Anus    when   the 

Mesentery  is  left  Long 614 


LIST  OF  ILLUSTRATIONS  xxvii 

FIO-  PAGE 

202.  Appearance  of  the  Intestine  where  the  Excess  of  Both  Bowel  and  Mesentery  has 

been  Removed  to  Prevent  Procidentia 615 

203.  Showing  Appearance  of  the  Gut  with  the  Excess  of  Mesentery  which  was  not 

Removed  During  the  Operation  of  Left  Inguinal  Colostomy,  and  which  Per- 
mits tne  Bowel  to  Protrude  from  Slight  Straining 616 

204.  Clamp  used  in  Gant's  Operation  for  the  Closure  of  an  Artificial  Anus.     (Exact 

Size)    620 

205.  Manner  of  Applying  Clamp  in  Gant's  Operation  for  the  Closure  of  an  Artificial 

Anus      621 

206.  Gant's  Clamp  in  Position  in  Operation  for  Closure  of  an  Artificial  Anus 622 

207.  Manner  of  Closing  External  Opening  After  the  Spur  has  been  Divided  in  Gant's 

Operation  for  the  Closure  of  an  Artificial  Anus 623 

208.  Hair  Ball  (Bezoar)  from  the  Intestine  of  a  Horse 636 

209.  Enterolith  from  the   Rectum 637 

210.  Urinary  Calculus,  Weighing  more  than  Four  Ounces,  which  Projected  into  the 

Rectum,  Causing  Stricture  and  Recto-vesical  Fistula 638 

211.  Extensive  Sloughing  and  Recto-urethral  Fistula  Secondary  to  Extravasation  of 

Urine  from  Rupture  of  the  Urethra,   Caused  by  a  Fall  and  Direct  Violence 

to  the   Perineum   , f47 

^12    Stick  Removed  from  the  Rectum  (Half-siae) 651 


LITERATURE 

PAGE 

Anatomy  and  Physiology   32 

Congenital  Malformations    (Abnormalities) 88 

Auto-infection     139 

Abnormalities  of  the  Coccyx 17£ 

The  Coccygeal  Body  (Luschka's  Gland) 172 

Coccygodynia     173 

Fractures  and  Dislocations  of  the  Coccyx 173 

Sacro-coccygeal  Tumors  173 

Venereal  Diseases    188 

Pruritus  Ani  (Itching  of  the  Anus,  Itching  Piles) 206 

Proctitis  and  Membranous  Colo-proctitis 222 

Ischio-rectal  Abscess  and  Periproctitis 232 

Ano-rectal  Fistula   284 

Fecal  Incontinence  293 

Fissure  in  Ano   317 

Non-malignant   Ulceration    34C 

Esthiomene    347 

Stricture   381 

Procidentia  Recti  407 

Hemorrhoids    471 

Non-malignant  Growths   (Polyps)    501 

Malignant   Tumors 577 

Colostomy    617 

Closure  of  Artificial  Anus  and  Fecal  Fistula 624 

Neuralgia    634 

Enteroliths  and  Intestinal  Calculi 643 

Foreign  Bodies,  Wounds,  and  Injuries 652 

Paderasty    658 

(xxviii) 


CHAPTER  I 

INTRODUCTION 

It  is  doubtful  if  any  part  of  the  body  is  so  frequently  the 
seat  of  annoying  and  painful  affections  as  is  the  ano-rectal  re- 
gion. The  suffering  induced  by  ailments  of  this  class  is  most 
intense,  and  may  be  local,  reflected  to  neighboring  organs  or 
parts  far  remote.  Persons  thus  afflicted  are  usually  disturbed 
in  mind  and  body  and  rendered  unfit  for  the  discharge  of  their 
social  and  other  duties. 

Rectal  disease  is  no  respecter  of  persons.  It  has  been 
encountered  in  both  sexes,  at  all  ages,  in  all  countries,  in  the 
various  walks  of  life,  and  under  varying  conditions.  There  are 
many  factors  which  play  their  respective  parts  in  the  produc- 
tion of  pathologic  conditions  in  this  locality.  Perhaps  the 
most  frequent  cause  is  constipation  resulting  from  irregulari- 
ties in  sleeping,  eating,  and  attending  to  the  calls  of  Nature ; 
dissipation,  and  sedentary  life. 

The  well-to-do  are  frequent  sufferers  from  hemorrhoids, 
pruritus,  and  proctitis  induced  by  overindulgence  in  highly 
seasoned  foods  and  alcoholic  beverages,  while  the  poor  are 
commonly  afflicted  with  prolapse,  fissures,  abscess,  and  fistula, 
caused  by  exposure,  unhygienic  surroundings,  hard  labor,  and 
the  poor  quality  of  their  diet.  Warm  climates  predispose  to 
rectal  ailments  because  of  the  prevalence  there  of  dysentery 
and  other  intestinal  diseases. 

Disease  and  tumors  of  neighboring  organs  and  structures 
occasionally  extend  to  the  rectum,  and  it  is  not  rare  for  disease 
of  this  organ  to  be  mistaken  for  prostatic,  urethral,  vesical, 
vaginal,  or  uterine  aft'ections.  Heredity  undoubtedly  plays  a 
part  in  the  etiology  of  rectal  affections,  but  not  to  such  an 
extent  as  the  writings  of  some  authors  on  the  subject  would 
indicate. 

The  most  potent  causes  of  disease  in  the  terminal  colon 
are  to  be  sought  in  the  anatomic  construction  of  the  rectum 
and  anus,  their  functions  in  life,  and  their  close  relation  with 
neighboring  organs  and  the  sacrum  and  coccyx.  Disease  in 
the  anal  region,  which  at  first  is  of  such  a  nature  as  to  be  easilv 

(1) 


2  DISEASES  OF  THE  RECTUM  AND  ANUS 

cured  by  simple  remedies,  sometimes  becomes  chronic  and  in- 
curable if  let  alone.  In  some  cases  this  sad  state  of  affairs  may- 
result  from  false  modesty  on  the  part  of  the  patients,  who  defer 
a  consultation  until  suffering  compels  it.  In  others  the  fault 
lies  with  the  attending  physician,  who,  because  of  indifference 
or  repugnance,  fails  to  make  a  proper  examination.  It  is 
deplorable,  but  nevertheless  a  fact,  that  many  physicians  are 
only  too  glad  to  avail  themselves  of  the  ready-made  diagnosis 
handed  out  by  the  patients,  and  then  proceed  to  prescribe  for 
them  accordingly. 

Happily  for  these  sufferers,  the  time  has  arrived  when 
ignorant  and  careless  practitioners  are  being  forced  out  of 
the  profession.  Their  places  are  rapidly  being  taken  by  pains- 
taking men  who  have  been  taught  the  value  of  making  an 
accurate  diagnosis  by  the  newer  methods  of  rectal  examina- 
tion, and  the  necessity  of  attending  to  this  class  of  affections 
promptly  and  in  a  scientific  manner. 

It  is  gratifying  to  note  the  increased  recognition  of  the 
proctologist  by  both  the  profession  and  the  laity,  who  are  be- 
ginning to  realize  that  most  affections  occurring  in  the  anal 
region  are  speedily  amenable  to  proper  treatment  when  taken 
in  time.  Since  there  is  no  longer  an  unexplored,  mysterious 
cavern  in  the  fundament  of  man,  it  is  to  be  hoped  that  the 
itinerant  "Pile  Doctor"  will  die  of  inanition,  and  the  faithful 
worker  in  medicine  ''thrive  and  grow  fat''  on  fees  long  delayed, 
but  rightfully  his  own. 


CHAPTER  II 

ANATOMY  AND  PHYSIOLOGY 

It  not  infrequently  happens  that  in  certain  rectal  diseases 
the  surgeon  is  called  upon  to  establish  an  artificial  anus  in  the 
ascending,  transverse,  or  descending  colon  or  the  sigmoid 
flexure,  depending  upon  the  location  of  the  lesion  for  which 
the  operation  is  made,  and  he  is  also  required  to  treat  other 
diseases,  involving  not  only  the  rectum,  but  other  parts  of 
the  large  intestine.  Hence,  in  a  work  of  this  kind,  it  is  essen- 
tial that  the  anatomy  of  the  large  intestine  (excepting  the 
appendix),  from  the  ileo-cecal  valve  to  the  anus,  should  be 
given.  The  author  will  not  attempt  a  description  of  the  mi- 
nute anatomy  of  these  parts,  but  will  give  sufficient  informa- 
tion to  enable  the  operator  in  this  field  of  surgery  to  work 
with  a  degree  of  intelligence. 

The  large  intestine  is  that  part  of  the  alimentary  canal 
extending  from  the  ileo-cecal  valve  to  the  anus.  It  is  so 
named  because,  when  undistended,  it  is  larger  than  the  pre- 
ceding portion  of  the  intestine.  It  is  further  differentiated 
from  the  latter  by  its  nearly  constant  position,  its  greater  de- 
gree of  fixation,  thicker  walls,  sacculated  contour,  and  longi- 
tudinal bands.  To  it  are  attached  the  appendices  epiploicce.  It 
is  five  or  six  feet  (1.6  to  1.9  meters)  in  length,  and  in  its 
course  describes  a  semicircle.  Beginning  at  the  ileo-cecal 
valve  in  a  blind  pouch  (the  cecum),  it  passes  upward  to  the 
Hver  (ascending  colon),  where  it  makes  a  sharp  turn  (hepatic 
flexure)  and  extends  across  the  abdomen  to  the  spleen  (trans- 
verse colon).  At  this  point  it  turns  downward  (splenic  flex- 
ure), to  descend  to  the  upper  part  of  the  left  iliac  region 
(descending  colon),  where  it  makes  a  number  of  curves  (sig- 
moid colon),  and  continues  in  an  irregular  manner  to  terminate 
at  the  anal  orifice  (rectum).  It  gradually  diminishes  in  size 
throughout  its  length. 

The  structure  of  the  cecum;  ascending,  transverse,  and 
descending  colons;  and  the  sigmoid  colon  is  the  same.     Their, 

(3) 


4  DISEASES  OF  THE  RECTUM  AND  ANUS 

coats  are  four  in  number,  viz. :  serous  (peritoneal),  muscular, 
submucous,  and  mucous. 

The  Serous  Coat  (peritoneal)  usually  completely  surrounds 
the  cecum  and  the  loop  of  sigmoid  colon,  while  the  remainder 
of  the  sigmoid  colon,  the  ascending,  descending,  and  trans- 
verse colon  are  only  partially  covered,  a  part  of  their  posterior 
surfaces  being  devoid  of  peritoneum. 

The  Muscular  Coat  consists  of  tv^o  layers  of  involuntary 
muscular  fibers,  the  outer  layer  being  longitudinal  and  the  in- 
ner circular.  The  outer  layer,  at  three  equidistant  points,  is 
gathered  into  longitudinal  bands  half  an  inch  (1.27  centime- 
ters) wide  and  about  one-twentieth  of  an  inch  (1.2  millime- 
ters) thick,  which,  on  account  of  their  shortness,  produce  the 
saccidations  of  the  intestine.  The  inner,  or  circular,  layer  of 
fibers  is  comparatively  thin  and  unbroken,  being  slightly  thick- 
ened between  the  sacculations. 

The  Submucosa  (vascular  coat)  is  a  layer  of  connective 
tissue  immediately  beneath  the  mucous  membrane,  and  in  it 
are  found  the  blood-vessels,  nerves,  and  lymphatics.  Its 
structure  is  such  that  the  mucous  membrane  may  glide  freely 
over  it. 

The  Mucous  Membrane  is  grayish  in  color,  and  consists  of 
(a)  muscularis  mucoscc;  (b)  stroma,  which  contains  lymphoid 
tissue,  blood-vessels,  and  nerve-elements ;  (c)  a  delicate  mem- 
brane supporting  the  columnar  epithelium.  In  the  mucous 
membrane  are  found  crypts  of  Lieberkiihn  and  solitary  glands 
or  follicles.  The  former  are  tubular,  very  numerous,  in  close 
apposition,  and  open  on  the  surface ;  the  latter  are  irregularly 
distributed  throughout  the  colon,  but  more  abundant  at  its 
beginning. 

The  large  intestine  derives  its  blood-supply  from  the  ileo- 
colic, coHca  dextra,  and  colica  media  from  the  superior  mes- 
enteric, and  the  colica  sinistra  and  sigmoidea  from  the  inferior 
mesenteric.  The  venous  blood  is  collected  by  the  superior  and 
inferior  mesenteric  veins,  and  is  then  emptied  into  the  portal 

vein. 

The  Lymphatics  of  the  large  intestine  are  in  two  sets :  one 
lying  under  the  crypts  of  Lieberkiihn  and  the  other  in  the  sub- 
mucosa. The  lymphatics  of  the  sigmoid  colon  empty  into  the 
lumbar  glands,  and  those  of  the  other  part  of  the  large  in- 
testine open  into  the  mesenteric  glands. 


ANATOMY  AND  PHYSIOLOGY  5 

The  large  intestine  receives  its  nerve-supply  from  the 
sympathetic  system.  The  filaments  going  to  the  cecum,  the 
ascending  and  the  first  half  of  the  transverse  colon  are  from 
the  superior  mesenteric  plexus,  from  the  celiac  plexus;  while 
the  remainder  of  the  colon  is  supplied  by  the  inferior  mesen- 
teric plexus,  a  derivative  of  the  aortic  plexus. 

The  Omenta  frequently  cause  the  surgeon  much  annoy- 
ance in  operations  upon  the  large  intestine  by  obscuring  the 
view  or  by  constantly  protruding  through  the  incision  and 
thus  interfering  with  his  work.  That  portion  of  the  omentum 
attaching  the  transverse  colon  to  the  greater  curvature  of  the 
stomach  is  known  as  the  gastro-colic  omentum.      It  is  apron- 


Fig.  l.^Recto-colonic  Diverticulse.  Photograph  of  Specimen  in  the  Carnegie 
Laboratory,  which  the  Author  was  Permitted  to  Photograph  Through  the 
Kindness  of  Dr.  McAlpin. 


Tike,  and  hangs  down  over  the  small  intestines.  It  is  con- 
nected on  the  right  with  the  hepatic  flexure,  and  on  the  left 
with  the  splenic  flexure  and  descending  colon,  where  it  is  called 
the  omentum  colicum. 

The  transverse  and  sigmoid  colons  are  invariably  attached 
to  the  posterior  abdominal  wall  by  mesocolons,  and  in  35  per 
cent,  the  descending  and  in  25  per  cent,  the  ascending  colons 
have  similar  attachments.  The  cecum,  however,  never  has 
such  a  connection. 

The  location  of  the  different  parts  of  the  colon  is  variable, 
owing  to  abnormalities  and  the  enlargement  of  neighboring 
viscera.     Sometimes  diverticula  (Fig.  1)  are  found,  leading  of¥ 


DISEASES  OF  THE  RECTUM  AND  ANUS 


from  the  colon  or  rectum,  and  when  distended  with  feces  they 
may  be  mistaken  for  tumors. 

SIGMOID   COLON    (SIGMOID   FLEXURE) 

The  close  relation  of  the  sigmoid  colon  and  rectum,  and 
the  frequency  with  which  disease  of  one  extends  to  the  other, 
necessitate  a  full  description  of  the  anatomy  of  both  in  a  work 
of  this  scope. 

The  Sigmoid  Colon  (Fig.  2,  S)  is  the  irregularly  (S-shaped) 
arranged  portion  of  the  large  intestine  occupying  the  left  iliac 


Fig.  2.— Showing  Location  of  Sigmoid  Colon  and  its  Relation  to  the  Rectum 
(Schematic).  S,  Sigmoid  Colon;  D,  Dividing-line  Between  it  and  Rectum; 
B,  Rectal  Ampulla;  A,  Anus;  V,  Anal  Canal;  L,  Part  of  Sigmoid  Loop  in 
the  Right  Iliac  Fossa. 

fossa.  It  begins  above  at  the  crest  of  the  ilium,  and  termi- 
nates in  the  rectum  at  the  left  sacro-iliac  articulation  or  in 
front  of  the  upper  edge  of  the  sacrum. 

The  upper  portion  has  a  peritoneal  covering  anteriorly 
and  laterally;  the  lower  segment  has  a  mesocolon,  possesses 
greater  mobility  and  a  double  curve,  from  which  the  sigmoid 
colon  derives  its  name.  The  narrowest  part  of  the  sigmoid 
is  at  its  junction  with  the  rectum  (Fig.  2,  D).  The  longitudi- 
nal muscular  bands  (slightly  developed  in  infants),  which  are 
prominent  in  the  upper  part  of  the  sigmoid,  become  less  pro- 
nounced  and   thinner   in   the   lower   part,   where   they   finally 


ANATOMY  AND  PHYSIOLOGY  7 

lose  their  characteristic  appearance,  their  fibers  becoming 
evenly  distributed  and  continuous  with  those  of  the  rectum. 
"The  mucous  membrane  of  the  sigmoid  and  rectum  consti- 
tutes the  greater  part  of  the  thickness  of  the  gut-wall  in  in- 
fants, and  is  more  firmly  attached  to  the  muscular  coats  than 
in  adults"  (Martin). 

The  location  of  the  sigmoid  colon  is  uncertain  both  in 
health  and  disease.  This  depends  upon  many  things,  viz.: 
(a)  abnormalities,  (b)  its  length,  (c)  length  of  its  mesenteric 
attachments,  (d)  distension,  (e)  pressure  of  the  abdominal 
expulsory  muscles,  (f)  tumors  and  distension  of  the  adjacent 
oigans,  and  (g)  sudden  and  violent  injuries.  In  the  empty 
state  it  remains  in  the  left  ihac  fossa  or  dips  down  into  the 
pelvis;  but  as  it  fills  it  extends,  with  a  rotary  motion,  upward 
or  across  the  pelvis  and  well  into  the  right  ihac  fossa,  where 
it  usually  remains  until  the  beginning  of  defecation.  In  the 
abnormal  state  it  has  been  encountered  either  loose  or  bound 
down  by  adhesions,  in  nearly  every  part  of  the  abdomen,  some- 
times as  a  straight  tube  and  at  others  twisted  into  irregular 
loops.  These  are  unnatural  conditions,  which  are  always  con- 
fusing to  the  surgeon.  Many  of  the  most  recent  writers  are 
in  favor  of  adding  to  the  sigmoid  colon  that  portion  of  the 
rectum  which  lies  above  the  middle  of  the  third  sacral  ver- 
tebra. This  change  in  the  topography  of  these  parts  seems 
a  rational  one,  because  it  fixes  the  dividing-line  with  greater 
certainty;  and  that  portion  of  the  intestine  above  this  line, 
described  as  the  sigmoid  colon,  has  a  mesentery,  and  that  below 
it,  described  as  rectum,  has  no  mesentery.  The  sigmoid  is 
usually  described  as  being  about  fourteen  inches  (36  centime- 
ters) long,  but  by  the  above  arrangement  from  three  and  one- 
half  to  four  inches  (9  to  10  centimeters)  are  added  to  its  length. 
In  two  hundred  subjects  examined  by  Byron  Robinson,  the 
longest  sigmoid  colon  encountered  was  thirty-three  inches  (85 
centimeters)  and  the  shortest  five  inches  (12.5  centimeters), 
the  average  length  being  eighteen  and  one-third  inches  (46 
centimeters).  Its  average  length  was  found  to  be  about  one 
and  one-half  inches  (4.8  centimeters)  more  in  men  than  in 
women. 

The  Sigmoid  Mesocolon  is  of  variable  length.  It  is  slightly 
longer  in  men  than  in  women  and  surrounds  the  sigmoid  colon, 
anchoring  it  above  in  the  left  iliac  fossa  on  the  left  side  of  the 


8  DISEASES  OF  THE  RECTUM  AND  ANUS 

psoas  muscle  (variable),  and  below,  just  above  the  third  sacral 
vertebra  (formerly  mesorectum).  It  is  of  sufficient  length  to 
give  a  wide  range  of  mobility  to  the  sigmoid  loop. 

RECTUM  (RECTUS  =  STRAIGHT) 

The  inferior  portion  of  the  colon  and  alimentary  canal  is 
called  the  rectum,  a  misnomer  in  the  human  species;  the  term 
originated  from  the  usual  straight  form  which  this  organ  pre- 
sents in  the  lower  animals. 

It  is  tubular,  devoid  of  longitudinal  bands,  and  is  nar- 
rowest at  its  junction  with  the  sigmoid  flexure  and  at  the  anal 


Fig.  3.— Paraffln-Injected  Rectum  and  Sigmoid,  Showing  the  Curves,  Mesen- 
tery, Bladder,  and  Recto-vesical  Fold  of  Peritoneum  (from  Child  Three 
Years  Old). 

extremity.  The  largest  part  of  the  rectum  (ampulla)  is  mov- 
able, begins  at  the  crossing  of  the  levator  ani  muscle,  extends 
upward  several  inches ;  its  anterior  and  posterior  walls  remain 
in  contact,  presenting  a  transverse  slit.  In  that  portion  of  the 
rectum  below  the  levator  ani  muscle  (anal  canal)  its  lateral  walls 
are  in  contact,  presenting  an  antero-posterior  slit. 

Relations  of  the  Rectum. — The  rectum  is  in  close  apposition 
anteriorly  with  the  small  intestine,  recto-vesical  pouch,  bladder 
(Fig.  3),  prostate,  seminal  vesicles,  and  urethra  in  the  male; 
and  with  the  uterus,  vagina,  Douglas's  cul-de-sac,  and  small 
intestine  in  the  female ;    posteriorly  with  the  mesorectum,  left 


ANATOMY  AND  PHYSIOLOGY  9 

pyriformis  muscle,  sacral  plexus,  internal  iliac  vessels,  sacral 
vertebrae,  coccyx,  Luschka's  gland,  middle  sacral  vessels,  and 
coccygei  muscles.  Its  length  varies  from  six  to  eight  inches 
(15  centimeters  to  2  decimeters),  the  latter  measurement  being 
more  common  in  advanced  life,  for,  as  age  increases,  the  tort- 
uosity of  the  bowel  is  more  marked.  Beginning  in  the  left  iliac 
fossa,  it  is  continuous  above  with  the  sigmoid  flexure  and  termi- 
nates below  at  the  anus.  In  rare  instances  the  position  of  the 
abdominal  viscera  is  reversed ;  in  such  cases  the  rectum  would 
necessarily  commence  on  the  right  side.  At  its  commencement 
it  curves  downward  toward  the  right  side  of  the  pelvis  three 
and  one-half  inches  (8.8  centimeters),  by  which  it  is  brought 
to  the  median  line  of  the  sacrum  at  a  point  opposite  the  third 
sacral  vertebra.  It  then  descends  obliquely  forward  and  down- 
ward for  about  three  inches  (7.5  centimeters),  at  which  point 
it  is  found  opposite  the  apex  of  the  coccyx;  from  this  point 
it  turns  upon  itself,  backward  and  downward,  for  about  one 
and  a  half  inches  (3.8  centimeters),  thus  completing  its  course 
at  the  anus.  It  is  obvious  that,  in  introducing  the  finger  into 
the  rectum,  it  should  be  passed  upward  and  forward. 

Like  the  hollow  abdominal  viscera,  the  rectum  has  four 
coats, — peritoneal,  muscular,  submucous,  and  mucous, — the  first 
being  only  partial,  while  the  others  are  continuous  throughout. 
Ordinarily  it  is  that  portion  not  covered  by  peritoneum  which 
is  the  seat  of  disease. 

The  above  description  of  the  direction  and  different  parts 
of  the  rectum  corresponds  to  that  commonly  given  by  anat- 
omists. Experience  has  shown  that,  from  a  practical  stand- 
point, this  arrangement  is  not  satisfactory.  At  this  writing 
there  is  a  general  tendency  among  both  proctologists  and 
anatomists  to  consider  as  the  rectum  only  that  portion  of  the 
lower  bowel  situated  below  the  third  sacral  vertebra,  and  which 
is  devoid  of  mesentery.  The  portion  of  the  large  intestine 
above  this  dividing-line,  which  is  entirely  covered  by  mesen- 
tery, and  heretofore  called  a  part  of  the  rectum,  is  now  re- 
garded as  a  part  of  the  sigmoid  flexure  (sigmoid  colon). 

The  author  deems  this  change  a  good  one,  for  the  reason 
that,  by  it,  the  term  "rectum"  is  applied  only  to  that  portion 
of  the  intestine  which  is  practically  straight  and  which  it  prop- 
erly describes. 

This   division   permits   the  rectum  to   be   subdivided,   for 


10  DISEASES  OF  THE  RECTUM  AND  ANUS 

clinic  purposes,  into  two  parts :  the  movable  rectum  (prin- 
cipally ampulla)  and  the  anal  canal  (fixed  rectum). 

The  movable  rectum  is  that  portion  of  the  lower  bowel 
which  begins  on  a  level  with  the  middle  of  the  third  sacral 
vertebra  and  terminates  at  the  levator  ani  muscle.  This  is 
the  largest  part  of  the  rectum,  the  lowermost  part  of  which 
is  known  as  the  ampulla  (Fig.  2,  R).  It  is  capable  of  being 
moved  laterally  or  vertically.  Its  anterior  and  posterior  walls 
He  in  contact,  but  it  may  be  distended  by  inflation,  and  then 
appears  to  be  divided  into  compartments  of  variable  size,  de- 
pending on  the  number  of  Houston's  "valves"  present  and  the 
distance  between  them.  Because  of  this  arrangement,  Martin 
suggests  that  the  lowermost  chamber  be  considered  as  the  first 
rectal  chamber;  the  cavernous  area  beyond  the  first  valve  and 
below  the  second  should  be  called  the  second  rectal  chamber; 
and  the  uppermost,  the  third,  or  perhaps  fourth,  according  to 
the  number  of  "valves"  present. 

The  upper  rectum  is  less  sensitive  than  the  lower,  as  is 
shown  by  the  slight  pain  caused  by  extensive  ulceration  or  by 
malignancy  in  this  region. 

The  anal  canal  (fixed  rectum;  Fig.  2,  C)  is  that  portion 
of  the  rectum  lying  between  the  levator  ani  above  and  the 
anus  below,  and  is  embraced  by  the  sphincter-muscles.  Its 
lateral  walls  are  in  contact  except  at  the  extremities,  where 
they  diverge  slightly. 

"The  length  of  the  fixed  anal  rectum  is  variable  with  a 
state  of  activity  or  passivity,  and  in  a  state  of  activity  there 
are  variations  in  its  length  of  at  least  one  inch  (2.54  centi- 
meters) between  a  contracted  uplifted  pelvic  floor  and  that  of 
a  depressed  floor  with  anal  eversion."     (Martin.) 

The  canal  is  surrounded  by  the  hemorrhoidal  plexus.  The 
most  painful  affections  of  the  ano-rectal  region  occur  usually 
in  the  anal  canal,  and  the  accompanying  pain  is  due  to  the 
contraction  of  the  surrounding  muscles  and  to  the  generous 
distribution  of  nerves  in  these  parts.  This  portion  of  the  rec- 
tum never  contains  feces  except  during  defecation. 

Peritoneal  Coat. — At  its  commencement  the  rectum  is  gen- 
erally surrounded  by  peritoneum,  which  binds  it  to  the  sacrum 
(Fig.  4) ;  lower  down  it  covers  the  anterior  surface  only,  and 
is  then  reflected  on  to  the  bladder,  forming  the  recto-vesical 
pouch  (Plate  II),  or  to  the  uterus  (Douglas's  cul-de-sac).    The 


PLMTE  n 


RBctum  InJBctEd  with  Paraffin,  showing  Positian  af  Sigmoid  and  Relation  of  ths 
PBritaneum  to  the  Sacrum,  Rsctum,  and  Bladder  [Stick  in  Bladder] . 


ANATOMY  AND  PHYSIOLOGY  H 

uterus  and  vagina  are  interposed  between  it  and  the  bladder 
in  the  female.  The  peritoneum  may  extend  down  to  within  an 
inch  (2.54  centimeters)  of  the  prostate;  the  distance  is  liable 
to  variations,  depending  on  the  age  of  the  subject  and  the  dis- 
tension of  neighboring  organs.  In  the  newborn  it  may  extend 
to  within  half  an  inch  (1.27  centimeters)  of  the  anus.  The  dis- 
tance increases  after  the  fifth  year;  in  old  age  with  enlarged 
prostate  the  peritoneum  is  found  higher  up.  The  distance  from 
the  anus  to  the  lower  portion  of  the  peritoneal  fold  has  been 
a  subject  of  much  controversy  both  at  home  and  abroad.    The 


Fig.  4.— Lateral  View  of  Paraffin-Injected  Rectum,  Showing  Mesentery,  Di- 
rection of  Blood-vessels,  and  Peritoneum  Binding  the  Rectum  and  Sacrum 
Together. 

author's  observations  lead  him  to  believe  that  two  and  a  half 
or  three  inches  (6.35  centimeters)  in  the  male  and  three  and  a 
half  inches  (9.9  centimeters)  in  the  female,  with  an  additional 
inch  (2.54  centimeters)  when  both  bladder  and  rectum  are  dis- 
tended, is  about  the  average  distance  from  the  anus  to  the 
commencement  of  the  peritoneum. 

Muscular  Coat. —  This  coat  is  thicker  and  stronger  than  in 
other  portions  of  the  large  intestine.  It  consists  of  two  layers, 
viz. :  circular  or  inner,  and  longitudinal  or  outer.  The  fibers 
of  the  latter  are  partly  prolongations  of  those  of  the  colon, 
while   the   arrangement   of   some   are   peculiar   to   the   rectum. 


12  DISEASES  OF  THE  RECTUM  AND  ANUS 

They  are  poorly  developed  in  early  childhood,  more  numerous 
in  the  anterior  and  posterior  portions  of  the  rectum,  and  by 
their  action  prevent  its  being  thrown  into  folds  as  in  the  colon. 
They  also  seem  to  be  more  abundant  in  the  upper  than  in  the 
lower  portion.  The  circular  fibers  are  neither  particularly 
strong  nor  numerous  in  the  upper  rectum,  but  become  stronger 
and  more  abundant  at  the  lower  end  of  the  rectum.  There  they 
form  a  muscular  band  about  an  inch  (2.54  centimeters)  in 
width :   the  internal  sphincter  muscle. 

Submucosa. — The  submucous  coat  is  a  layer  of  more  or  less 
dense  connective  tissue  in  which  the  blood-vessels,  nerves,  and 
lymphatics  ramify.  It  is  sufficiently  lax  to  permit  free  gliding 
of  the  mucous  membrane  over  it.  In  inflammatory  disease 
this  coat  is  often  thickened,  indurated,  and  rigid,  and  becomes 
adherent  to  the  muscular  layer  and  the  mucous  membrane, 
frequently  interfering  with  the  mobility  of  the  latter. 

Mucous  Membrane. — The  mucous  membrane  of  the  rectum- 
is  much  thicker,  more  generously  supplied  with  blood-vessels, 
and  glides  over  the  underlying  structures  more  freely  than  in 
other  parts  of  the  colon.  When  the  rectum  is  empty,  the 
mucous  membrane  of  the  upper  part  is  thrown  into  multitude 
of  superficial,  transverse,  velvety  folds,  which  are  obliterated 
when  it  is  distended.  From  two  to  seven  folds  (Houston's 
"valves")  are  made  more  prominent  by  distension.  Because  of 
their  importance,  these  so-called  "valves"  will  be  described  at 
length  elsewhere  in  this  chapter. 

The  epithelium  covering  the  mucous  membrane  is  of  the 
columnar  variety  and  similar  to  that  of  the  colon  above.  The 
mucous  cells,  however,  are  much  more  plentiful. 

"The  transitional  epithelium  between  skin  and  rectal  mu- 
cosa is  a  narrow  zone  of  thick,  stratified  epithelium,  the  pecten, 
containing  nerve-elements  which  the  writer  believes  to  be  the 
peripheral  ends  of  nerves  concerned  with  a  special  rectal  sense. 
The  zone  varies  in  width  from  three  to  nine  millimeters  (}/^ 
to  ^/g  inch).  Its  caudal  border  is  about  at  the  junction  of  the 
ectal  and  ental  sphincters.  The  cephalic  (upper)  border  is 
demarcated  by  the  linea  dentata."     (Stroud.) 

Numerous  crypts  of  LieberkUhn  are  found  in  the  mucous 
membrane  of  the  rectum,  and  beneath  them  solitary  lymphoid 
nodules  resembling  the  solitary  follicles  of  the  small  intestine. 
The  tubular,  or  mucus-secreting,   cells  are   so  multitudinous 


ANATOMY  AND  PHYSIOLOGY  13 

that,  when  viewed  through  a  lens,  the  membrane  presents  a 
honey-combed  appearance. 

The  absorbing  power  of  the  mucous  membrane  is  remark- 
able, and  is  clearly  demonstrated  by  the  good  results  obtained 
from  rectal  alimentation  and  medication. 

Beginning  just  above  the  muco-cutaneous  junction  (Hil- 
ton's white  line)  and  extending  upward  for  a  distance  of  eight 
to  fourteen  milHmeters  (Vs  to  ^/g  inch)  are  several  (four  to 
ten)  projecting,  longitudinal  plicae  caused  by  sphincteric  con- 
traction, and  known  as  the  columns  of  Morgagni.  These  col- 
umns are  broader  above  than  below,  contain  muscular  fibers 
(longitudinal),  and  are  difhcult  to  efface. 

Suspended  between  the  lower  extremities  of  Morgagni's 
columns  are  transverse,  cup-shaped  folds  of  the  mucous  mem- 
brane from  a  twelfth  to  a  sixth  of  an  inch  (4  millimeters)  in 
depth,  which  are  known  as  the  semilunar  valves  (sacciili  Hor- 
neri,  Fig.  94),  the  function  of  which  is  to  collect  mucus  for  the 
lubrication  of  the  feces.  These  semilunar  valves  have  been 
frequently  described  as  pockets.  Located  at  the  lower  end  of 
Morgagni's  columns  are  several  (ten  to  fourteen)  minute  ele- 
vations (so-called  papillce),  composed  chiefly  of  stratified  epi- 
thelium and  a  slight  amount  of  connective  tissue,  each  con- 
taining an  arteriole  and  a  nerve-filament.  "They  are  important 
tactile  organs  connected  with  a  special  rectal  sense"  (Andrews). 
It  is  doubtful  if  they  are  invariably  present ;  at  least,  the  writer 
has  been  unable  to  demonstrate  them  with  any  degree  of  cer- 
tainty except  when  they  have  undergone  pathologic  changes. 

Self-styled  "orificial  surgeons"  have  written  in  extenso 
about  these  "pockets"  (semilunar  valves)  and  "papillae,"  and 
would  lead  both  the  profession  and  laity  to  believe  that  these 
structures  are  most  fruitful  sources  of  human  suffering,  which 
can  be  relieved  only  by  "cHpping  them  out"  or  "snipping  them 
off."     In  reality,  such  is  seldom  the  case. 

Occasionally  the  seniilunar  valves  are  found  abnormally 
developed  or  they  became  ulcerated  or  torn,  forming  a  fissure. 
They  sometimes  serve  as  an  outlet  for  fistulous  sinuses  or  as 
a  receptacle  for  seeds  and  small  particles  of  fecal  matter,  caus- 
ing local  and  reflected  pain.  The  "papillae"  are  seldom  the 
seat  of  disease  primarily,  but  they  frequently  become  enlarged 
and  project  into  the  lumen  of  the  bowel,  in  cases  where  the 
rectum   is   constantly   bathed   with   irritating  secretions   from 


14  DISEASES  OF  THE  RECTUM  AND  ANUS 

disease  (cancer,  proctitis,  etc.)  in  the  colon  and  upper  rectum. 
They  then  appear  as  pyramidal  eminences  varying  from  a  six- 
teenth (1.5  milHmeters)  to  a  half  inch  (1.27  centimeters)  in 
height,  the  apex  being  of  a  grayish  color,  owing  to  the  absence 
of  blood-vessels,  while  the  lower  part  is  somewhat  more  highly 
colored  than  the  surrounding  mucous  membrane.  (Plate 
XVIII.) 

ARTERIES 

The  arteries  of  the  rectum  are  derived  from  three  distinct 
sources : — 

1.  The  superior  hemorrhoidal,  from  the  inferior  mesen- 
teric. 

2.  The  middle  hemorrhoidal,  from  a  branch  of  the  inter- 
nal iliac. 

3.  The  inferior  hemorrhoidal,  from  the  internal  pudic  after 
it  has  re-entered  the  pelvis. 

The  Superior  Hemorrhoidal. — This  artery  descends  through 
the  mesorectum  and  divides  into  two  branches,  which  course 
along  the  posterior  wall  of  the  rectum.  They  are  at  first  su- 
perficial, but  soon  perforate  the  muscular  coat  and  give  ofT  a 
number  of  branches,  which  anastomose  in  the  mucous  mem- 
brane and  submucosa,  not  only  with  each  other,  but  with  the 
middle  and  frequently  with  the  inferior  hemorrhoidal  arteries. 
The  main  branches  run  parallel  with  the  bowel.  This  accounts 
for  the  slight  bleeding  from  incisions  made  parallel  with  the 
long  axis  and  the  profuseness  of  hemorrhage  from  those  made 
at  a  right  angle  to  the  bowel. 

Middle  Hemorrhoidal  Arteries. — These  arteries  vary  in  size 
and  take  an  oblique  course  downward  to  supply  the  middle 
third  of  the  rectum. 

Inferior  Hemorrhoidal  Arteries. — These  vessels  send  branches 
upward  as  well  as  downward  to  anastomose  with  the  other 
hemorrhoidal  arteries  and  to  supply  the  levator  ani,  sphincter- 
muscles,  and  cellular,  fatty,  and  tegumentary  tissues  in  the  anal 
region. 

VEINS 

The  veins  correspond  in  name  with  the  arteries.  The 
middle  and  inferior  hemorrhoidal  veins  return  the  blood  from 
the  anal  region  to  the  internal  iliac.     The  JieniorrJioidal  plexus 


ANATOMY  AND  PHYSIOLOGY  15 

of  enlarged  and  anastomosing  veins  is  situated  in  the  lower 
part  of  the  rectum,  and  from  it  proceeds  the  "superior  hemor- 
rhoidal vein,"  which  has  no  valves,  but  which  returns  the  blood 
from  the  rectum  proper  to  the  portal  system.  Quenu  believes 
this  plexus  communicates  freely  with  the  branches  of  the  in- 
ferior hemorrhoidal,  but  has  httle  in  common  with  those  of 
the  middle  hemorrhoidal  veins.  The  superior  hemorrhoidal 
vein  and  its  branches  pass  upward  under  the  mucous  membrane 
for  a  distance  of  about  three  or  four  inches  (7.62  or  10.16 
centimeters),  then  perforate  the  muscular  coat  at  four  or  five 
points,  and  can  be  seen  on  the  outside  of  the  bowel.  Verneuil 
has  laid  much  stress  on  this  anatomic  fact,  claiming  that  the 
veins  pass  through  muscular  button-holes,  which  have  the  power 
of  contracting  around  them,  closing  their  caliber,  and  pre- 
venting a  return  of  the  blood  to  the  liver.  In  this  anatomic 
arrangement,  he  believes,  is  to  be  found  the  active  cause  of 
internal  hemorrhoids. 

NERVES 

The  nerves  are  derived  from  the  two  great  classes  which 
go  to  make  up  the  nervous  system :  the  cerebro-spinal  and  the 
sympathetic.  Those  originating  from  the  former  come  from 
the  sacral  plexus,  and  those  of  the  latter  from  the  mesenteric 
and  hypogastric  plexuses.  The  muscles  of  the  anal  region  are 
supplied  by  branches  of  the  sacral  nerves,  while  the  superficial 
perineal  of  the  pndic  supplies  the  levator  ani  and  skin  in  front 
of  the  anus.  The  inferior  hemorrhoidal  (of  the  pudic)  branch 
supplies  the  lower  end  of  the  rectum  and  anus.  The  pudic  is 
controlled  by  the  same  part  of  the  cord  as  the  sciatic.  Hence 
irritation  from  a  fissure  or  ulcer  located  within  the  anus  may 
be  transferred  down  the  limbs  or  to  other  distant  parts.  The 
intimate  relation  of  this  nerve  to  the  genito-urinary  organs 
explains  the  frequency  with  which  disorders  of  micturition  are 
associated  with  rectal  affections.  The  upper  and  middle  por- 
tions of  the  rectum  are  much  less  sensitive  than  the  lower,  as 
has  been  proven  by  experiments  made  by  Bodenhamer.  The 
pain  increases  in  proportion  as  the  disease  encroaches  upon 
the  anal  margin;  hence  disease,  malignant  or  otherwise,  situ- 
ated high  up  may  cause  little  pain.  The  sympathetic  nerve  is 
distributed  to  the  rectum  and  anus  and  is  derived  from  the 
hypogastric,   which   is   formed   by   branches   from   the   aortic 


16  DISEASES  OF  THE  RECTUM  AND  ANUS 

plexus.     It  also  receives  branches  from  the  lumbar  and  sacral 
plexuses. 

LYMPHATICS 

The  absorbent  vessels  of  the  ano-rectal  region  are  of  goodly 
size  and  much  more  numerous  than  is  generally  supposed. 
They  consist  of  two  systems,  those  of  the  skin  and  anus  being 
distinct  from  those  of  the  rectum,  the  former  going  to  the  in- 
guinal and  the  latter  to  the  sacral  and  the  lumbar  glands.  This 
accounts  for  the  clinical  fact  of  infiltrated  inguinal  glands  from 
malignancy  at  the  anal  margin,  and  a  similar  condition  of  the 
sacral  and  lumbar  glands  when  the  rectum  is  involved.  Mr. 
Cripps,  however,  has  recorded  two  cases  of  infiltrated  inguinal 
glands  when  the  disease  was  situated  high  up  in  the  rectum. 

The  gluteal  nodes  derive  their  lymph  from  the  buttocks, 
and  convey  it  to  the  iliac  nodes. 

MUSCLES 

The  muscles  which  are  of  especial  interest  in  the  study  of 
the  rectal  diseases  are  six  in  number,  viz. :  the  corrugator  cutis 
ani,  external  sphincter,  transversus  perinei,  internal  sphincter,, 
recto-coccygeus,  and  levator  ani. 

Corrugator  Cutis  Ani. — This  muscle  consists  of  a  thin  layer 
of  involuntary  muscular  fibers  surrounding  the  anus,  which 
blend  internally  with  the  submucosa  and  externally  with  the 
integument.  By  contracting,  it  gathers  the  skin  about  the  anus 
into  folds. 

External  Sphincter. — This  muscle  is  voluntary,  and  is  situ- 
ated immediately  beneath  the  integument  at  the  anal  margin. 
It  is  about  three  inches  (7.62  centimeters)  in  length,  half  an 
inch  (1.27  centimeters)  broad,  and  is  quite  thin.  It  arises  from 
the  tip  of  the  coccyx,  and,  after  surrounding  the  anus  in  the 
form  of  an  ellipse,  is  inserted  into  the  central  tendon  of  the 
perineum.  The  action  of  this  muscle  is  to  close  the  anal  orifice 
and  assist  in  the  expulsion  of  the  feces,  acting  in  conjunction 
with  the  abdominal  muscles  and  levator  ani.  Its  nerve-supply 
is  derived  from  the  fourth  sacral  and  the  inferior  hemorrhoidal 
of  the  internal  pudic,  and  the  center  controlHng  it  is  situated 
in  the  lumbar  enlargement  of  the  cord. 

Transversus  Perinei. — This  muscle  arises  by  a  narrow  ten- 
don on  the  anterior  surface   of  the  tuber  ischii,   and  passes 


PLATE  ni.—LEVATORES  ANI  A8  SEEN  FROM  ABOVE,  SHOWING 

HOW    THEY   PASS  AROUND  THE  RECTUM. 

A,  Bladder.        B^  Prostate.        C,  Reotum.        B  D,  Levatores  am. 


ANATOMY  AND  PHYSIOLOGY  17 

forward  and  inward  to  be  inserted  into  the  central  tendon  of 
the  perineum  at  the  junction  with  the  anterior  insertion  of  the 
external  sphincter,  and,  in  the  female,  with  the  posterior  at- 
tachment of  the  sphincter  vaginae.  According  to  Cruveilhier, 
it  aids  in  defecation  by  pressing  the  anterior  and  posterior 
walls  of  the  bowel  together,  in  conjunction  with  the  external 
sphincter. 

Internal  Sphincter.  —  This  is  a  fiat,  involuntary  muscular 
band  formed  by  a  collection  of  the  fibers  of  the  circular  coat, 
lying  immediately  above  the  external  sphincter.  It  is  from 
three-fourths  of  an  inch  (1.9  centimeters)  to  an  inch  (2.54 
centimeters)  in  breadth,  and  one-sixth  of  an  inch  (4.2  milli- 
meters) in  thickness.  Its  fibers  are  somewhat  finer  and  paler 
than  those  of  the  external  sphincter. 

Recto-coccygeus  Muscle. — United  with  the  internal  sphincter 
muscle  are  the  unstriated  bands  which  arise  from  the  anterior 
surface  of  the  coccyx,  and  are  known  as  the  recto-coccygeus  mus- 
cle. It  embraces  the  lower  end  of  the  rectum  in  a  fork,  and 
draws  the  rectum  upward  toward  the  apex  of  the  coccyx  after 
it  is  forced  down  during  the  act  of  defecation. 

Levator  Ani  (Lifter  of  the  Anus). — The  origin  and  insertion 
of  this  muscle,  as  well  as  its  action,  have  been  the  subject  of 
much  study  and  controversy.  From  the  dissections  made  by 
the  writer,  he  believes,  with  Mr.  Cripps,  that  a  large  portion 
of  its  fibers  arises  from  the  inner  surface  of  the  symphysis  pubis 
and  from  half  an  inch  (1.27  centimeters)  of  the  anterior  por- 
tion of  the  white  line,  and  passes  obliquely  downward  and  back- 
ward to  be  inserted  into  the  sides  of  the  rectum  and  coccyx. 
These  fibers  cross  the  rectum  at  right  angles  two  and  a  half 
inches  (6.35  centimeters)  above  the  anus. 

The  action  of  the  levator  ani,  in  so  far  as  the  rectum  is 
concerned,  is  to  compress  the  sides  of  the  rectum  and  the  neck 
of  the  bladder,  and  in  the  act  of  defecation,  when  the  sphincter 
relaxes  to  open  the  anus,  it  closes  the  urethra.  This  explains 
in  part  the  well-known  difficulty  of  voiding  urine  and  feces 
at  the  same  time.  The  accompanying  schematic  drawings 
show  very  nicely  the  relation  of  the  levator  ani  to  the  rectum. 
(Plates  III  and  IV.) 

The  levator  ani  also  partly  forms  the  floor  of  the  pelvis, 
giving  support  to  the  pelvic  organs.  In  addition  to  this  it 
has  a  voluntary  sphincteric  action,  which  can  be  demonstrated 


18  DISEASES  OF  THE  RECTUM  AND  ANUS 

by  introducing  the  finger  into  the  bowel  and  requesting  the 
patient  to  draw  up  the  anus  as  much  as  possible,  when  a  con- 
traction will  be  felt  from  one  and  a  half  to  two  inches  (3.8 
to  5.08  centimeters)  above  the  anus.  This  action,  which  Mr. 
Cripps  attributes  to  the  levator  ani,  would,  in  part,  account 
for  the  control  of  the  bowel  that  is  frequently  seen  to  ex- 
ist after  complete  destruction  of  the  external  and  internal 
sphincters.  Again,  after  certain  rectal  operations  where  the 
sphincter-muscles  have  been  thoroughly  divulsed,  patients 
often  complain  of  sudden  jerking  about  the  anus,  and  this  is 
undoubtedly  due  to  the  action  of  the  levator  ani. 

THE   ANUS 

The  anus  is  an  oval  orifice  in  which  the  anal  canal  ends. 
It  is  placed  about  one  inch  (2.54  centimeters)  in  front  of  the 
tip  of  the  coccyx  and  between  the  tuber  ischii  (above  them  in 
the  male).  It  is  lined  above  by  mucous  membrane  and  below 
by  integument  which  is  firm,  deeply  pigmented,  and  provided 
with  numerous  papillae,  hairs,  and  sebaceous  follicles,  the  latter 
supplying  an  unctuous  secretion  with  a  disagreeable  odor. 
The  skin  about  the  anus  is  gathered  into  numerous  radiating 
folds  by  the  corrugator  cutis  ani  muscle. 

The  anus  may  be  thoroughly  stretched  in  every  direction 
without  permanently  impairing  its  functions.  In  health,  the 
orifice  is  closed  by  the  external  sphincter;  but,  in  cancer, 
stricture,  extensive  ulceration,  and  other  grave  diseases  of  the 
rectum,  this  muscle  may  become  worn  out  or  destroyed,  and 
the  anus  becomes  patulous,  causing  partial  or  complete  in- 
continence. 

PERIRECTAL   SPACES 

The  rectum  is  surrounded  by  loose  connective  tissue  and 
fascia,  the  latter  derived  principally  from  the  pelvic  fascia. 
"Between  the  rectum  and  sacrum  is  a  large  space,  devoid  of 
fat,  called  the  retrorectal  space,  and  between  the  rectum,  semi- 
nal vesicles,  and  the  recto-vesical  fascia  is  another  space  of 
considerable  size  called  the  prerectal  space''  (Quenu).  Wal- 
deyer,  in  speaking  of  the  latter  space,  claims  that  it  is  isolated 
laterally  from  the  retrorectal  space  by  the  junction  of  the 
parietal  and  pelvic  fascia  and  above  it  is  lost  in  the  subperi- 
toneal tissue  of  the  bladder.     He  does  not  believe  that  the 


PLATE   IV—LEVAT0RE8   ANI,   SIDE    VIEW,   SHOWING    THEIR 

RELATION  TO   THE  RECTUM. 

A  A,  Levatores  ani.  B,  Rectum. 


ANATOMY  AND  PHYSIOLOGY  19 

lateral  spaces,  described  by  Quenu,  are  deserving  of  special 
consideration.  He  further  says  that  the  anal  canal  does  not 
come  into  relationship  with  any  of  these  spaces. 

ISCHIO=RECTAL   FOSS/E 

On  either  side  of  the  lower  end  of  the  rectum,  between 
it  and  the  tuber  is-chii,  are  two  large  spaces  filled  with  fat, 
and  which  are  called  the  ischio-rectal  fosses.  They  are  triangu- 
lar in  shape,  with  the  apices  directed  upward  and  the  bases 
toward  the  skin.  Their  depth  varies  from  one  and  a  half  inches 
(3.8  centimeters)  in  front  to  two  inches  (5.18  centimeters)  be- 
hind, and  at  their  lowermost  and  broadest  part  they  are  a  little 
more  than  an  inch  (2.54  centimeters)  in  width.  Internally  these 
spaces  are  in  relation  to  the  external  and  internal  sphincters, 
coccygeus,  and  levator  ani  muscles;  externally  with  the  tuber 
ischii  and  obturator  fascia ;  anteriorly  with  superficial  and  peri- 
neal fascias;  and  posteriorly  with  the  border  of  the  gluteus 
maximus  muscles,  the  investing  fascia  of  which  is  continuous 
with  the  great  sacro-sciatic  ligament.  Within  a  sheath  formed 
by  the  obturator  fascia  are  to  be  found  the  internal  pudic 
artery,  veins,  and  nerves.  The  inferior  heinorrlwidal  vessels  and 
nerves  pass  through  the  central  portion  of  the  ischio-rectal 
fossae  on  their  way  to  the  anal  canal  to  which  they  are  dis- 
tributed, while  in  the  anterior  portion  of  these  spaces  are  the 
superficial  perineal  vessels  and  nerves.  The  fat  and  connective 
tissue  filling  these  spaces  act  as  elastic  supports  for  the  rectum 
and  are  largely  responsible  for  the  lateral  walls  of  the  rectum 
remaining  in  contact.  These  foss^  are  of  surgical  importance 
because  of  the  frequency  with  which  abscesses  and  Ustulas  are 
found  in  this  locality. 

THE   "RECTAL   VALVES"    (FOLDS) 

Houston's  "valves,"  Kohlrausch' s  plicce  transversalis  recti, 
sphincter  ani  tertiiis,  detrusor  fcccinm  muscles,  superior  sphincter. 

The  mucous  membrane  of  the  rectum,  as  previously  stated, 
is  thrown  into  numerous  superficial  riigce.  In  the  rectum  above 
the  anal  canal  are  three  or  four  large,  permanent,  transverse, 
or  oblique  semilunar  folds  which  project  a  considerable  dis- 
tance into  the  lumen  of  the  bowel.  These  folds  are  at  present 
the  subject  of  much  controversy.     Some  writers  maintain  that 


20  DISEASES  OF  THE  RECTUM  AND  ANUS 

they  are  not  always  present  and,  if  present,  are  effaceable  by 
distension ;  others  are  equally  positive  of  their  existence  in  all 
persons  and  at  all  ages,  and  that  they  become  more  prominent 
in  proportion  as  the  rectum  is  distended.  Because  of  the  wide 
interest  which  these  folds  have  aroused  and  the  difference  of 
opinion  as  to  their  existence,  number,  location,  arrangement, 
structure,  functions,  and  pathologic  significance,  they  will  be 
described  at  length  and  in  such  a  manner  that  it  is  hoped  the 
reader  may  have  a  clear  understanding  of  them. 

Cloquet,  ]\Iorgagni,  and  Portal  were  among  the  first  to 
mention  these  folds  and  to  speak  of  them  as  "valves.'"  Mr.  John 
Houston,  of  Dublin,  was  the  first  writer  to  clearly  describe  the 
"rectal  valves'' ;  to  point  out  their  location,  number,  and  ar- 
rangement; and  to  assign  to  them  a  function.  This  he  did  in 
a  paper  published  in  the  Dublin  Hospital  Reports,  in  1830,  since 
which  time  they  have  been  known  as  Houston  s  "valves."  Ac- 
cording to  his  description,  they  were  usually  three  or  some- 
times four  and  occasionally  more  in  numl^er,  semilunar  in  shape 
with  the  concavity  directed  upward,  and  occupying  from  one- 
third  to  one-half  of  the  circumference  of  the  gut;  they  were 
from  one-half  to  three-fourths  of  an  inch  (1.27  to  2  centimeters) 
or  more  in  breadth  in  the  distended  state  of  the  rectum,  their 
lateral  surfaces  horizontal  or  oblique.  Houston  held  that  they 
were  composed  of  a  folding  of  the  mucous  membrane  inclosing 
cellular  tissue  and  circular  muscular  fibers.  He  described  the 
most  prominent  "valve"  as  situated  on  the  anterior  rectal  wah 
opposite  the  base  of  the  bladder  and  at  a  point  three  inches 
above  the  anus ;  the  "valve"  next  in  importance  as  situated  at 
the  upper  end  of  the  rectum  and  projecting  from  the  right  wall ; 
the  third  as  on  the  left  wall  midway  between  these  two ;  and  the 
fourth,  when  present,  as  attached  to  the  bowel  one  inch  above 
the  anus  toward  the  left  and  posterior  wall.  The  whole  ar- 
rangement was  such  as  to  form  a  sort  of  spiral  tract,  giving  to 
the  upper  rectum  a  sacculated  appearance.  He  demonstrated 
the  existence  of  the  "valves"  by  distending  and  hardening  the 
rectum  with  spirit  and  then  cutting  it  open,  and  maintained  that 
this  was  the  only  way  by  which  they  were  demonstrable. 

Mr.  Houston  claimed  that  the  function  of  these  "valves" 
was  to  support  the  fecal  column  and  prevent  its  too  rapid  de- 
scent upon  the  anal  canal,  which  would  produce  a  desire  to 
stool.    He  also  pointed  out  that  they  frequently  interfered  with 


ANATOMY  AND  PHYSIOLOGY  21 

the  passage  of  instruments,  and,  further,  that  they  were  a 
fruitful  source  of  stricture. 

Shortly  afterward  Nelaton  and  Velpeau  described  a  col- 
lection of  muscular  fibers  encircling  the  bowel  at  a  point  four 
inches  (10.16  centimeters)  above  the  anus,  and  about  one-half 
inch  (1.27  centimeters)  in  width,  thinner  posteriorly  than  ante- 
riorly. They  beHeved  this  muscular  band  kept  the  rectum 
empty  in  the  intervals  of  defecation,  guarded  the  upper  rectum 
from  a  return  of  the  feces,  and  further  prevented  complete  in- 
continence after  the  sphincters  had  been  destroyed.  Sappey 
conceded  the  presence  of  this  muscle,  but  maintained  that  it 
did  not  entirely  surround  the  bowel;  furthermore,  he  believed 
that  it  was  usually  found  on  a  level  with  the  base  of  the  pros- 
tate. Henle  agreed  with  Sappey  in  regard  to  the  arrangement 
and  location  of  this  muscular  band.  Hyrtl  named  this  muscle 
the  "spJwicter  ani  tertius,"  beheving  that  it  possessed  sphincteric 
action. 

Chadwick  opposed  the  views  of  Hyrtl  as  to  the  function 
of  the  third  sphincter,  because  his  experiments  convinced  him 
that,  in  the  passive  state,  the  lumen  of  the  bowel  at  this  point 
was  not  less  than  three-fourths  of  an  inch  (2  centimeters),  and, 
further,  because  he  was  unable  to  find  a  well-marked  muscle 
in  the  location  described,  but  did  find  two  irregular  collections 
of  circular  fibers :  one  on  the  anterior  wall  at  the  site  of  Hyrtl's 
third  sphincter  and  the  other  on  the  posterior  wall  one  inch 
(2.54  centimeters)  above  the  first.  These  he  named  the  detrusor 
fcEcium  muscles,  and  maintained  that  their  function  was  to  aid 
in  the  act  of  defecation  by  contracting  behind  the  feces  and 
pushing  them  downward. 

Kohlrausch,  in  1854,  vividly  described  a  large,  transverse, 
semilunar  fold  which  did  not  disappear  upon  distending  the 
rectum  and  which  was  situated  about  six  or  eight  centimeters 
(2  to  3  inches)  above  the  anus  opposite  the  third  sacral  ver- 
tebra and  projected  about  fifteen  millimeters  (^/g  inch)  from 
the  right  and  anterior  walls  of  the  rectum.  He  called  it  the 
plica  transversalis  recti.  His  description  of  this  fold  corre- 
sponds to  that  of  the  "most  prominent  'valve'"  as  given  by 
Houston. 

The  next  most  scientific  and  practical  contribution  to  the 
literature  of  the  "rectal  valves"  was  made,  in  1887,  by  an  Amer- 
ican, Dr.  Walter  J.  Otis.    He  described  how  the  "valves"  might 


22  DISEASES  OF  THE  RECTUM  AND  ANUS 

be  demonstrated  by  placing  the  subject  in  the  knee-chest 
posture  and  holding  the  anus  open  with  retractors,  thus  allow- 
ing the  rectum  to  become  inflated.  The  ordinary  mucous  folds 
immediately  disappeared,  but  the  "valves,"  or  permanent  folds, 
remained  prominent,  projecting  from  left  to  right,  one  above 
the  other,  and  dividing  the  rectum  into  compartments.  His 
description  of  the  permanent  folds  agrees,  in  the  main,  with 
that  given  by  Houston  as  to  the  shape,  dimensions,  location, 
and  structure  of  the  "valves" ;  but,  as  a  rule,  he  found  only  two 
constant  folds,  while  occasionally  a  third  one,  less  prominent, 
could  be  seen.  He  held  that  they  did  not  support  the  fecal 
mass,  but  aided  in  its  expulsion,  and,  for  this  reason,  he  desig- 
nated them  plica  recti,  right  and  left.  Otis  believed  that  the 
sphincter  ani  tertius  {superior  sphincter)  of  Hyrtl  was  simply  a 
collection  of  circular  muscle-fibers,  irregular  in  number  and 
location. 

Van  Buren,  in  speaking  of  the  "valves,"  concludes  his  re- 
marks by  stating  that  anatomists  and  physiologists  have  been 
equally  unsuccessful  in  assigning  to  them  either  certainty  of 
function  or  constancy  of  location. 

Bodenhamer  insists  that  the  ''valves''  are  accidental  folds 
resembling  the  valviilce  conniventes  of  the  small  intestine,  and, 
while  admitting  that  they  look  like  "valves,"  claims  that  they 
lack  the  essential  attributes,  and  are  not  sufficiently  large  and 
strong  to  obstruct  or  dam  up  the  inferior  extremity  of  the 
rectum. 

Quenu  and  Hartmann  describe  the  "valves,"  and  further 
state  that  they  form  a  distinct  compartment  one  or  two  centi- 
meters (V2  to  ^/4  inch)  in  depth. 

Kelsey,  in  summing  up  his  discussion  on  the  presence  and 
functions  of  the  "rectal  valves"  and  third  or  superior  sphincter, 
says :  "From  a  study  of  the  literature  of  this  question,  and  from 
results  of  dissection  and  experiments  which  we  have  person- 
ally been  able  to  make,  we  are  led  to  the  following  conclu- 
sions : — 

"1.  What  has  been  so  often  and  so  diflferently  described 
as  a  third  or  superior  sphincter  ani  muscle  is,  in  reality,  noth- 
ing more  than  a  band  of  the  circular  muscular  fibers  of  the 
rectum. 

"2.  This  band  is  not  constant  in  its  situation  or  size,  and 


ANATOMY  AND  PHYSIOLOGY  23 

may  be  found  anywhere  over  an  area  of  three  inches  (7.62 
centimeters)  in  the  upper  part  of  the  rectum. 

"3.  The  folds  of  mucous  membrane  (Houston's  'valves') 
which  have  been  associated  with  these  bands  of  muscular 
tissue  stand  in  no  necessary  relation  with  them,  being  also  in- 
constant, and  varying  much  in  size  and  position  in  different 
persons. 

"4.  There  is  nothing  in  the  physiology  of  the  act  of 
defecation,  as  at  present  understood,  or,  in  fact,  of  a  certain 
amount  of  continence  of  feces  after  extirpation  of  the  anus, 
which  necessitates  the  idea  of  the  existence  of  a  superior 
sphincter. 

"5.  When  a  fold  of  the  mucous  membrane  is  found  which 
contains  muscular  tissue,  and  is  firm  enough  to  act  as  a  barrier 
to  the  descent  of  the  feces,  the  arrangement  may  fairly  be  con- 
sidered an  abnormality,  and  is  very  apt  to  produce  the  usual 
signs  of  stricture." 

Mathews,  after  citing  Houston  in  regard  to  the  location 
of  the  "rectal  valves,"  dismisses  the  subject  as  follows:  "I  deny 
their  existence,  and,  if  they  did  exist,  I  would  deny  that  their 
use  was  'to  support  the  fecal  mass.' 

"For  many  years  I  have  searched  for  these  folds,  and  I 
have  yet  to  encounter  them.  In  my  opinion,  they  exist  only 
in  the  author's  mind's  eye." 

Martin  states  that  the  prominence  of  the  "valves"  is  in- 
creased by  distension  of  the  rectum,  and  that  they  are  com- 
posed of  the  mucosa,  beneath  which  is  a  heavy  layer  of  fibrous 
tissue,  bundles  of  circular  muscular  fibers  in  the  middle  of  the 
"valves,"  and  at  the  base  arteries  and  veins  for  their  special  nu- 
trition. These  structures,  he  holds,  constitute  a  typic  anatomic 
^'valve."  He  says:  "The  number  of  'rectal  valves'  is  variable. 
Some  subjects  have  but  two,  others  have  four,  but  90  per  cent, 
of  persons  possess  three.  The  uppermost  'valve'  is  invariably 
situated  at  the  juncture  of  the  rectum  and  the  sigmoid  flexure, 
which  'valve'  is  invariably  situated  on  the  left;  the  next  lower 
one  is  on  the  right  wall,  and  the  lowermost  is  on  the  left.  The 
positions  of  the  lower  two  'valves'  are  sometimes  anterior  and 
posterior."  In  regard  to  their  physiologic  significance,  Martin 
maintains  that  the  "rectal  valves"  have  a  function  and  are  en- 
dowed with  passive  and  active  properties.  In  this  regard  he 
says:    "When  the  muscular  elements  are  relaxed  and  the  gut 


24  DISEASES  OF  THE  RECTUM  AND  ANUS 

is  greatly  dilated  or  else  in  a  lesser  measure  distended,  the 
'valve'  is  passively  projected  across  the  channel,  to  resist  the 
hurried  or  uncontrolled  descent  of  the  feces.  The  presence 
of  the  bands  of  fibrous  tissue  under  the  free  margin  of  the 
'valve'  provides  a  guard,  or  control,  to  receive  and  retain  the 
bolus,  or,  I  may  say,  the  'valves'  receive  a  series  of  boluses, 
till  sufficient  pressure  is  made  to  stimulate  the  complex  in- 
voluntary mechanism  of  defecation  to  an  expulsion  of  the  feces 
or  to  a  reversed  peristalsis."  And  again :  "If  it  be  the  func- 
tion of  the  normal  'rectal  valve'  to  beneficently  retard  the 
descent  of  the  feces,  it  is  obviously  true  that  it  may  be  the 
especial  property  of  the  'valve'  in  certain  other  than  normal 
conditions  to  maliciously  obstruct  the  descent  of  the  feces. 

"There  are  three  forms  of  'valvular'  obstruction : — 

"1.  Anatomic  coarctation  of  the  'valves'  may  afford  an  ex- 
aggerated physiologic  resistance  to  the  descent  of  the  feces. 

"2.  Congenital  hyperplasia  of  tJie  'rectal  valve'  is  a  condition 
classically  described  as  diaphragmatic  stricture  or  membranous 
septum  in  the  abdominal  rectum. 

"3.  Hypertrophy  of  the  'rectal  valve'  constitutes  the  classic 
annular  stricture  of  the  abdominal  rectum." 

Pennington's  description  of  the  location  and  structure  of 
the  "rectal  valves"  agrees  with  Martin's  in  its  essential  points, 
but  he  has  gone  a  step  farther  and  shown  that,  in  many  in- 
stances, the  longitudinal  muscular  fibers  are  prominent  in  the 
"valves."  "Sometimes  the  longitudinal  muscle  spans  the  base 
of  the  "valve" ;  and,  again,  it  splits,  some  fibers  following  the 
circular  coat  and  some  spanning  the  base.  In  some  instances 
it  extends  well  into  the  tip  in  all  the  'valves.'" 

In  regard  to  the  function  of  the  "rectal  valves,"  Penning- 
ton says :  "From  experimental  studies  made  upon  the  living 
and  the  dead,  it  would  seem  that  the  function  of  these  plicae 
is  (1)  to  prevent  the  feces  from  crowding  down  upon  the  anus 
when  the  bowel  is  in  a  passive  state,  (2)  to  equalize  the  press- 
ure of  feces  that  may  accumulate  in  the  rectum  from  time  to 
time,  and  (3)  to  facilitate  defecation  by  giving  a  spiral  motion 
to  the  fecal  mass."  He  further  believes  that,  as  a  result  of 
mechanic  and  infectious  agencies,  a  sort  of  chronic  inflam- 
mation may  occur  in  the  rectum  favoring  hyperplasia  of  the 
"valves,"  which  sooner  or  later  becomes  a  factor  in  chronic  con- 
stipation or  obstipation.     He  says :   "The  intestinal  wall  is  fre- 


PLHTE  If 


Rectum  Out  Dpen,  showing  Two  "Rectal  Halves"  Situated  Hlmast  Uirectly 
Opposite,  One  Just  Mhoue  the  Other,  [Paraffin  Cast,  shown  in  Plate  III, 
was  Removed  from  this  Specimen.] 


ANATOMY  AND  PHYSIOLOGY  35 

quently  pouched  and  thinned  immediately  above  the  base  of 
the  Valve/  and  hypertrophied  opposite  the  'valve's'  free  bor- 
der." 

From  the  foregoing  it  will  be  seen  that  investigators 
differ  widely  in  their  conclusions  as  to  the  constancy,  number, 
location,  structure,  and  function  of  the  "rectal  valves,"  and  also 
that  at  the  present  time  httle  information  on  this  subject  is 
to  be  gained  from  text-books  on  either  anatomy  or  surgery. 
Most  writers  on  diseases  of  the  rectum  and  anus  fail  to  men- 
tion them,  or,  having  mentioned  them,  ascribe  but  little  or  no 
importance  to  their  existence :  opinions  which  are  seemingly 
founded  on  clinic  experience  rather  than  on  original  research. 

In  the  previous  edition  of  this  work  the  author,  after 
quoting  Houston  in  regard  to  the  number,  size,  location,  and 
function  of  the  rectal  folds  ("valves"),  gave  it  as  his  opinion 
that  they  became  almost  obliterated  by  distension,  a  conviction 
founded  principally  upon  clinic  experience  without  the  aid  of 
the  proctoscope  and  rectal  inflation.  Observations  and  experi- 
ments made  by  him  since  that  time  have  proven  to  his  satis- 
ifaction  that  the  converse  is  true. 

To  determine  the  location  and  constancy  of  the  "valves," 
the  author  examined  the  rectum,  either  distended  or  empty,  in 
several  hundred  subjects,  both  living  and  dead,  by  means  of 
the  proctoscope,  rectal  inflation,  and  digital  examination.  In 
addition  to  this,  with  the  subjects  in  different  positions,  he 
injected  post-mortem,  with  various  hardening  and  plastic  prep- 
arations (formalin,  alcohol,  plaster  of  Paris,  gelatin,  paraffin, 
etc.),  the  rectums  of  twenty-five  fetuses :  children  and  adults 
(Fig.  5).  After  a  sufficient  length  of  time  the  rectums  were 
removed,  cut  open,  and  examined  macroscopically.  Subse- 
quently sections  of  the  "valves"  were  made  and  examined  with 
the  microscope.  He  also  had  microscopic  examinations  made 
of  several  sections  taken  from  the  "valves"  in  living  subjects. 
The  "valves"  taken  from  these  subjects  differed  in  thickness 
and  rigidity. 

The  specimen  shown  in  Plate  V  was  prepared  by  inject- 
ing the  bowel  in  situ,  under  moderate  pressure,  with  paraffin, 
which  was  allowed  to  harden.  The  rectum  was  then  removed 
and  dried  for  one  week,  after  which  it  was  cut  open  and  the 
cast  (Plate  VI)  taken  out.  The  "valves"  were  very  well  shown 
(Plate  V),  but  not  in  their  usual  location.    They  were  uncom- 


26  DISEASES  OF  THE  RECTUM  AND  ANUS 

monly  close  together,  nearly  opposite  each  other,  and  formed 
almost  an  annular  stricture.  The  photomicrographs  (Plates 
VII  and  VIII)  of  sections  of  the  "valves,"  which  show  their 
structure  very  well,  were  made  by  Dr.  B.  H.  Buxton,  Histolo- 
gist  in  Cornell  University  Medical  College,  from  tissue  re- 
moved from  gross  specimens  prepared  by  the  author. 

The  following  description  of  the  constancy,  location,  and 
structure  of  the  "valves"  is  based  upon  the  results  of  the  above 
researches,  which,  in  the  main,  confirm  the  experiments  of 
Houston,  Otis,  Martin,  and  Pennington : — 

In  the  author's  opinion,  there  is  sufficient  evidence  to  war- 


Fig.  6.— Rectum  Distended  with  Three-per-cent.  Formaldehyde  Solution 
(when  Hardened  and  Opened  Showed  "Valves"  Beautifully). 

rant  the  assertion  that  the  various  folds,  muscles,  rings,  and 
bands  described  by  Houston,  Nelaton,  Hyrtl,  Kohlrausch,  and 
Otis  are  one  and  the  same  thing,  namely :  "Houston's  valves." 
When  the  sphincter-muscles  have  been  destroyed  by  dis- 
ease or  operation,  the  "valves"  may  check  the  downward  course 
of  the  feces  by  projecting  into  the  lumen  of  the  bowel,  but 
not  by  their  constricting  powers.  In  the  author's  opinion,  when 
incontinence  does  not  follow  destruction  of  the  sphincter-mus- 
cles it  is  due,  not  to  the  "valves,"  but  to  the  levatores  ani,  which. 
are  partially  under  control  of  the  will,  and  may  acquire  sphinc- 
teric  action. 


FLUTE  m 


Paraffin  Cast,  showing  Indentatians  made  by  Houston's  "Halves,"     [Removed 
from  Rectum  shown  in  Plates  II  and  II,] 


EXPLANATION  OF  PLATE  VII 


A  transverse  section  through  the  entire  "  valve." 

The  thin  black  line  all  around  is  the  mucous  mem- 
brane. Beneath  this  is  a  lighter  layer,  the  submucous 
tissue ;  while  the  inner  and  outer  muscular  coats, 
between  which  no  differentiation  can  be  made,  are 
represented  by  a  somewhat  darker  layer  internal  to  the 
submucous  tissue. 

Internal  to  the  muscular  layers  and  running  up 
almost  to  the  extreme  end  of  the  "  valve  "  is  the  subserous 
tissue,  consisting  of  loose  connective  tissue  and  fat. 

The  tissue  seems  to  be  greatly  shrunken  and  con- 
tracted, but  this  contraction  could  not  affect  the  general 
distribution  of  the  various  layers.  It  is  evident,  there- 
fore, that  both  the  muscular  coats  run  practically  up  to 
the  extreme  tip  of  the  "  valve  "  and  must  have  consider- 
able influence  on  its  action. 


ANATOMY  AND  PHYSIOLOGY  27 

Houston's  "valves"  are  permanent  anatomic  structures 
(made  more  prominent  by  distension),  capable  of  demonstra- 
tion in  either  the  hving  or  the  dead  fetus,  infant,  child,  or 
adult,  except  in  those  instances  in  which  they  have  been  de- 
stroyed by  disease  or  in  which,  because  of  pathologic  changes 
in  the  gut-wall,  rectal  inflation  is  impossible.  They  are  cres- 
cent-shaped, capable  of  vertical  motion,  extend  from  one-half 
to  two-thirds  around  the  circumference  of  the  rectum  (Plate 
V  and  Fig.  6),  and  project  into  its  lumen  from  three-fourths 
to  one  and  a  half  inches  (1.9  to  3.8  centimeters).  They  are 
directed  obliquely  to  the  long  axis  of  the  bowel,  and  are 
slightly  cup-shaped,  their  concavities  looking  upward.     When 


Fig.  6. — Proctoscopic  Bird's-Eye  View  of  "Valves"  in  an  Inflated  Rectum. 

the  bowel  is  distended,  the  free  margins  of  the  "valves"  stand 
out  prominently,  and  are  easily  seen  through  the  proctoscope, 
or  they  may  be  felt  by  the  finger  during  straining. 

The  niiinber  of  "valves"  is  variable.  Usually  there  are  three, 
sometimes  two  or  four  (Fig.  6) ;  in  exceptional  cases  there 
may  be  fiive,  six,  or  even  seven.  When  more  than  the  usual 
number  are  present,  some  of  them  are  small,  shallow,  and  less 
prominent.  The  location  of  the  "valves"  is  fairly  constant,  and 
is  as  follows :  The  upper  "valve''  at  the  junction  of  the  sigmoid 
colon  and  rectum  on  the  left  rectal  wall ;  the  middle  (most 
prominent,  Kohlrausch's  plicee  recti)  "valve"  on  the  right  ante- 
rior wall  opposite  the  base  of  the  bladder  and  three  inches 
(7.C2  centimeters)  or  more  above  the  anus;   the  loiver  "valve'' 


28  DISEASES  OF  THE  RECTUM  AND  ANUS 

on  the  left  side  a  short  distance  below  the  middle  "valve."  With 
the  patient  in  the  knee-chest  posture  and  the  rectum  well  in- 
flated, one  can  sometimes  see,  by  the  aid  of  the  proctoscope, 
all  of  the  "valves"  at  the  same  time  (Fig.  6).  In  exceptional 
cases  the  "valves"  may  be  located  one  above  the  other  or  almost 
directly  opposite  each  other  (Plate  V),  completely  hiding 
from  view  the  lumen  of  the  bowel  above  them.  Generally, 
however,  they  form  a  sort  of  spiral  stairway,  which  gives  a 
rotary  motion  to  the  fecal  mass  on  its  journey  from  the  sig- 
moid to  the  anal  canal. 

The  structure  of  the  "valves"  has  been  the  subject  of  much 
controversy.  The  difference  of  opinion  has  probably  arisen 
from  the  fact  that  their  structure  may  vary  in  the  same  sub- 
ject and  under  the  same  conditions,  and  that  the  make-up  of 
the  normal  is  always  different  from  that  of  the  hypertrophied 
or  diseased  "valve."  The  average  "valve"  is  composed  of :  (a) 
mucous  membrane ;  (b)  submucosa  (fibrous  layer) ;  (c)  cir- 
cular muscular  layer;  (d)  longitudinal  muscular  layer;  (e) 
subserous  layer,  consisting  of  areolar  tissue  and  fat,  and  ar- 
teries, veins,  nerve-elements,  and  lymphatics.  The  mucous 
membrane  covering  the  "valve"  is  of  variable  thickness  and  con- 
tinuous with  the  membrane  at  the  base  of  the  "valve"  (Plates 
VII  and  VIII).  It  consists  of  the  epithelial  lining,  the  stroma, 
and  the  miiscularis  miicoscE,  which  is  more  prominent  here  than 
in  other  parts  of  the  rectum.  The  submucosa  is  composed  of 
white,  fibrous  connective  tissue,  sometimes  forming  a  dense 
layer  (Plates  VII  and  VIII),  and  was  first  described  by  Martin, 
who  maintains  that  it  gives  support  to  the  "valves,"  especially 
when  they  are  hypertrophied. 

The  circular  layer  of  muscular  fibers  is  usually  constant, 
and  may  extend  only  a  short  distance  into  the  "valve"  or  almost 
to  its  tip  (Plates  VII  and  VIII).  The  longitudinal  layer  is 
present  less  often  than  the  circular,  and  may  extend  across 
the  base  of  the  "valve"  without  contributing  any  fibers  to  its 
structure;  or  it  may  dip  into  the  "valve,"  reaching  nearly  to 
the  distal  end  (Plate  VII).  In  addition  to  these  structures, 
Pennington  reports  finding  in  the  "valve"  lymph-nodes,  large 
sympathetic  ganglia,  epithelial  structures  imbedded  in  the 
loose  tissue  outside  the  longitudinal  muscular  layer,  and,  in 
one  specimen,  white  fibrous  and  yellow  elastic  tissue  in  the 
same  locality. 


EXPLANATION  OF  PLATE  YIU 


The  tip  of  the  "  valve  "  is  shown. 

Lining  the  outer  surface  is  the  deeply-staining 
mucous  membrane,  within  which  is  the  pale,  submucous 
coat,  composed  of  dense,  fibrous  tissue. 

The  third  layer,  staining  somewhat  more  deeply,  is 
the  inner  circular  muscular  coat,  and  internal  to  this 
is  the  outer  longitudinal  muscular  coat.  Loose  areolar 
and  adipose  tissue  fill  up  the  interval. 

The  extension  of  both  muscular  coats  almost  to  the 
extreme  tip  of  the  "  valve  "  is  well  shown. 


PLMTE  Tim 


■Rs-ctal  [HnuBton'sJ  Ualue  "  [Magnificatinn,  25],  showing  the  Mucosa,  Sub- 
mucasa,  Circular,  and  Longitudinal  Muscular  Coats,  as  they  Pass  up  to  the 
Tip  of  the  "  Halve," 


ANATOMY  AND  PHYSIOLOGY  39 

While  the  muscular  coat  usually  enters  into  the  structure 
of  the  "valves,"  the  latter  are  sometimes  made  up  entirely  of 
mucosa  and  submucosa. 

The  various  elements  composing  the  "valves"  are,  as  a 
rule,  more  clearly  defined  in  the  adult  than  in  the  infant. 

For  further  information  on  the  functions  of  the  "rectal 
valves"  the  reader  is  referred  to  the  section  on  the  physiology 
of  defecation;  and,  for  their  pathologic  significance,  to  the 
chapters  on  proctitis,  membranous  colitis,  abnormalities  of  the 
rectum  and  anus,  and  stricture  and  constipation. 


PHYSIOLOGY 

After  leaving  the  stomach  the  food  enters  the  small  intes- 
tine, where  intestinal  digestion  takes  place.  Certain  portions 
having  been  absorbed,  the  residue  passes  onward,  in  a  liquia 
state,  into  the  large  intestine,  where  it  remains  about  twelve 
hours,  during  which  time  the  surplus  water  is  absorbed  and 
the  mass  assumes  the  characteristic,  solid  fecal  form  in  which 
it  is  evacuated  through  the  anal  aperture.  The  feces  collect 
principally  in  the  sigmoid  colon,  where  they  remain  until  the 
beginning  of  defecation.  Because  of  its  shape,  attachments, 
and  location,  and  the  fact  that  it  is  narrowest  at  its  junction 
with  the  rectum,  the  sigmoid  colon  is  particularly  well  adapted 
for  this  purpose.  Foster  beHeves  that  the  sigmoid  containing 
the  feces  is  supported  by  the  bladder  and  sacrum.  O'Beirne 
held  to  the  opinion  that  the  feces  were  retained  in  the  sigmoid 
by  the  narrow  muscular  ring  at  its  junction  with  the  rectum. 
This  circular  constriction  is  called  the  spJiincter  of  O'Beirne. 

Defecation. — The  act  of  defecation  is  complicated,  and  is 
both  voluntary  and  involuntary.  Its  beginning  and  completion 
are  mainly  under  the  control  of  the  will,  while  the  intermediate 
stage  is  carried  out  by  an  involuntary  mechanism. 

After  a  certain  quantity  of  feces  and  gases  has  collected, 
the  pressure  or  the  stretching  of  the  muscular  fibers  by  dis- 
tension starts  up  peristaltic  action.  This  consists  of  a  series 
of  vermicular  contractions  of  the  longitudinal  muscular  fibers, 
immediately  followed  by  constriction  of  the  circular  fibers.  The 
former  cause  a  shortening  of  the  bowel  and  the  latter  a  cir- 
cular narrowing.  As  these  worm-like  movements  extend  from 
above  downward,  the  feces  are  forced  out  of  the  sigmoid  colon 


30  DISEASES  OF  THE  RECTUM  AND  ANUS 

into  the  rectum.  In  the  rectum  the  longitudinal  and  circular 
muscular  layers  have  each  a  distinct  nerve-supply.  That  of 
the  former  comes  from  the  cord  by  way  of  the  anterior  roots 
of  the  upper  sacral  nerves,  continuing  with  their  branches  to 
the  hypogastric  plexus,  and  thence  to  the  rectum.  The  sup- 
ply to  the  latter  is  derived  from  the  vasomotor  constrictor  area 
of  the  cord,  proceeding  from  it  by  the  anterior  roots  of  the 
lower  dorsal  and  upper  lumbar  nerves,  finally  reaching  the 
rectum  through  the  anterior  mesenteric  ganglia  and  the  hypo- 
gastric plexus. 

In  the  intervals  of  defecation  the  sphincter  is  in  a  state  of 
tonic  contraction.  The  center  which  largely  controls  this  mus- 
cle and  the  act  of  defecation  is  located  in  the  lumbar  enlarge- 
ment of  the  cord,  and  may  be  voluntarily  stimulated  or  in  a 
measure  inhibited.  Destruction  or  injury  to  this  part  of  the 
cord  results  in  permanent  relaxation  of  the  sphincter,  while  a 
similar  accident  to  the  dorsal  region  causes  only  temporary  re- 
laxation, the  muscle  soon  regaining  its  tonicity.  To  a  certain 
extent,  the  sphincter  is  influenced  by  a  center  in  the  brain, 
supposedly  located  in  the  optic  thalamus,  and  which  is  usually 
under  control  of  the  will.  Certain  emotions  or  sudden  fright, 
however,  may  result  in  relaxation  of  the  muscle  and  the  in- 
voluntary evacuation  of  feces. 

The  desire  to  stool  follows  immediately  upon  the  exit  of  the 
feces  and  gases  from  the  sigmoid  and  their  contact  with  the 
mucous  membrane  of  the  rectum.  The  exact  manner  in  which 
this  sensation  is  induced  has  never  been  satisfactorily  explained. 
No  one  has  been  able  to  clearly  demonstrate  whether  it  is  due 
to  pressure,  distension,  chemic  changes,  bacterial  action,  or 
other  causes.  The  desire  is  sometimes  created  by  irritating 
discharges,  sHght  or  profuse,  coming  from  disease  in  the  colon 
or  upper  rectum,  and  from  this  it  would  appear  that  it  does 
not  necessarily  depend  upon  the  accumulation  of  feces  in  the 
bowel. 

The  stimulus,  however  produced,  is,  according  to  Kirke, 
transmitted  to  the  center  in  the  cord,  through  the  hemor- 
rhoidal and  inferior  mesenteric  plexus,  and  is  then  reflected 
to  the  musculature  of  the  rectum  through  the  pudendal  plexus, 
resulting  in  a  relaxation  of  the  sphincter,  a  contraction  of  the 
muscular  gut-walls,  and  expulsion  of  the  feces. 

When  the  proper  time  for  defecation  has  arrived,  through 


ANATOMY  AND  PHYSIOLOGY  31 

a  voluntary  effort  the  glottis  is  closed  after  an  inspiration,  the 
diaphragm  is  forced  downward,  and  the  abdominal  muscles 
(especially  the  internal  oblique)  are  drawn  inward,  compressing 
the  abdominal  viscera  and  propelling  the  feces  on  their  down- 
ward course.  Immediately  after  their  exit  from  the  sigmoid 
they  come  in  contact  with  the  uppermost  Houston  "valve,"  on 
the  left  rectal  wall,  where  they  may  be  arrested  temporarily, 
or  immediately  glide  off  to  fall  upon  the  next  "valve"  on  the 
right  anterior  wall,  and  from  here,  in  the  same  manner,  they 
pass  to  the  lowermost  "valve"'  on  the  left  side  and  then  to  the 
fixed  rectum.  This  arrangement  permits  of  a  sort  of  rotary 
and  step-by-step  descent  of  the  feces,  thus  giving  the  levator 
ani  and  sphincter-muscles  time  to  prepare  for  their  approach. 
As  the  feces  are  pushed  toward  the  anal  canal,  the  levator  ani 
muscles  draw  the  canal  upward  and  over  them.  At  this  point 
peristalsis  and  pressure  by  the  abdominal  muscles  are  in- 
creased, forcing  the  feces  downward,  the  sphincter-muscle  vol- 
untarily relaxes  to  allow  of  their  passage,  while  the  levator 
ani  contracts  and  closes  in  behind  them,  thus  assisting  in  the 
completion  of  the  act  of  defecation. 

Every  healthy  person  should  have  one  fecal  evacuation 
in  twenty-four  hours.  The  fecal  mass  should  be  semisolid  in 
consistence,  rounded  in  form,  from  four  to  six  ounces  (120  to 
180  grams)  in  weight,  and  consist  of  about  75  per  cent,  water 
and  25  per  cent,  solids.  It  does  not  follow,  however,  that  in- 
creased or  diminished  frequency  of  the  stools  or  slight  change 
in  their  consistency  or  composition  is  indicative  of  serious  im- 
pairment of  health  (see  page  53). 

Writers  generally  agree  that,  when  the  desire  to  empty 
the  bowel  is  disregarded,  the  sensation  may  pass  away.  Be- 
cause of  this  and  the  fact  that  by  digital  examination  the 
rectum  is  in  such  cases  sometimes  found  empty,  O'Beirne  was 
led  to  believe  that  the  feces,  when  not  evacuated  at  the  proper 
time,  were  returned  to  the  sigmoid  by  reverse  peristalsis.  It 
has  been  the  writer's  experience  that  in  nearly  all  such  cases 
the  rectum  does  contain  a  fecal  accumulation.  The  author  be- 
lieves, however,  that  in  exceptional  cases  the  feces  may  be 
redeposited  in  the  sigmoid  colon.  To  determine  this  point  he 
has  frequently  instructed  patients  not  to  have  a  stool,  and  has 
examined  their  rectums  at  various  times  during  the  thirty-six 
hours  following.      In  most  instances  digital   examination   re- 


S3  DISEASES  OF  THE  RECTUM  AND  ANUS 

vealed  an  accumulation  of  feces  in  the  rectum,  but  in  a  few  the 
eadier  examinations  revealed  a  like  condition,  while  those 
made  later  showed  the  rectum  to  be  empty.  Further  evidences 
of  reverse  peristalsis  are  fecal  vomiting  in  cases  of  obstruction, 
the  removal  by  laparotomy  of  foreign  bodies  introduced  into 
the  rectum  some  days  before,  and  the  discharge,  several  days 
after  rectal  operations,  of  blood-clots,  the  presence  of  which 
in  the  rectum  previous  examination,  both  digital  and  procto- 
scopic, had  failed  to  reveal. 

Again,  the  lower  rectum  may  be  found  empty,  but  proc- 
toscopic examination  will  reveal  the  feces  above  and  supported 
by  the  ''valves."  Moreover,  if  the  entire  fecal  mass  is  not  dis- 
charged at  stool,  the  remaining  portion  may  sometimes  be 
seen  above  the  "valves." 

Absorption. — In  studying  the  functions  of  the  rectum  one 
must  not  overlook  the  fact  that  it  possesses  remarkable  powers 
of  absorption  and,  to  a  slight  extent,  digestion.  In  fact,  the 
constitutional  effects  of  some  drugs  are  most  quickly  obtained 
when  introduced  per  rectum,  and  in  some  cases  a  smaller  dose 
is  required.  Again,  the  action  of  the  drug  per  rectum  is  more 
certain,  because  it  is  less  liable  to  chemic  change  than  when 
administered  by  the  mouth. 

The  most  striking  example  of  rectal  absorption  is  shown 
in  the  benefits  derived  from  enemata  of  warm  saline  solutions 
employed  after  profuse  hemorrhage  or  surgical  shock. 

When  for  any  cause  food  cannot  be  taken  into  the  stom- 
ach, it  may  be  given  in  liquid  and  semisolid  form  per  rectum 
with  very  beneficial  results,  except  in  cases  where  the  mucous 
membrane  has  been  destroyed  by  local  disease. 


LITERATURE    ON    ANATOMY    AND    PHYSIOLOGY    OF    THE 
SIGMOID    AND    RECTUM 


Babcock:    "Anomalies  of  the  Colon,"  Internat.  Med.  Mag.,  x,  p.  129,  1900. 
Baughman:    "Sigmoid  Flexure,"  Mathews's  Med.  Quart.,  ii,  p.  312,  1895. 
Bodenhanier:    "Physical  Exploration  of  the  Rectum,"  pp.  4-18,  1870. 

"Valves  of  the  Rectum,"  !<!.  Y.  Med.  Jour.,  June  30,  1900. 
Busche:     "Treatise   on   Maltorm.,   Inj.,   and   Dis.    of   the   Rectum   and   Anus," 

1837. 
Chadwick:     Trans,  of  Amer.  Gi/necol.  Soc.,  ii,  p.  43,  1877. 
Deaver:    "Surgical  Anatomy,"  ii  and  iii,  1900. 


ANATOMY  AND  PHYSIOLOGY  33 

Foster:    "A  Text-book  of  Physiology,"  p.  382,  1895. 

Gerrish:     "Text-book   of  Anatomy,"   1899. 

Gray:     "Anatomy,   Descriptive   and   Surgical,"   1897. 

Hall:    "Text-book  of  Physiology,"   1900. 

Henle:     "Handb.  der  systemat.  Anat.  des  Menschen,"  ii,  1873. 

Horner:    "Spec.  Anat.  and  HistoL,"  ii,  pp.  47-48.    Philadelphia,  1843. 

Houston:    Diihlin  Hosp.  Reports,  v,  1830. 

Hyrtl:    "Handb.  der  topogr.  Anat.,"  Bd.  ii,  pp.  108-9.     Wien,  1857. 

Kelsey:    "Diseases  of  the  Rectum  and  Anus,"  p.  26,  1890. 

Kirke:    "Hand-book  of  Physiology."     Amer.  rev.  ed.,  1896. 

Kohlrausch:     "Anat.  u.   Physiol,   der  Beckenorgane."     Leipzig,   1854. 

Martin:    "Obstipation,"  Philadelphia  Hon.  Med.  Jour.,  i,  p.  421,  1899. 

"Difficult  Defecation  in  Infants,"  Jour.  Amer.  Med.  Association,  Feb., 

1898. 
Mathews:     "Fallacies  in  Rectal  Disease,"  Louisville  Mon.  Jour,  of  Med.  and 

Surg.,  vii,  p.  309,  1901. 
O'Beirne:    "New  Views  of  the  Process  of  Defecation,"  etc.     Dublin,  1833. 
Otis:     "Anatomische    Untersuchungen    am    menschlichen    Rectum    und    neue 

Methode  der  Mastdarminspection,"  1887. 
Pennington:    "Anat.,  Histol.,  and  Pathol,  of  the  Rectum  and  Colon,"  Chicago 

Med.  Recorder,  Dec,  1900. 
Poirier:     "Traite  d Anatomic  Humaine,"   iv,   1895. 
Quain:     "Anatomy,"  vol.  viii,  Pt.   IV,   1896. 
Quenu   and   Hartmann:     "Chirurgie   du   Rectum."      Paris,   1895. 
Robinson:    "The  Sigmoid  Flexure,"  Matheivs's  Med.  Quart.,  iii,  p.  239,  1896. 
Sappey:    "Traits  dAnat.     Descriptive."      Pans,  t.   iv,   1874. 
Stroud:    "On  the  Anat.  of  the  Anus,"  Annals  of  Surg.,  July,  1896. 
Van  Buren:    "On  Phantom  Stricture,"  etc.,  Amer.  Jour.  Med.  Sciences,  Oct., 

1879. 
Velpeau:     "Traits   d'Anat.   Chirurg.,"   3me   p.d.,  p.   39,   1837. 
Waldeyer:    "Das  Becken."     Bonn,  1899. 


CHAPTER  111 

SYMPTOMATOLOGY  (SEMEIOLOQY) 

The  syjnptoms,  local  and  reflex,  which  suggest  prodica 
are  many  and  varied.  For  this  reason  it  is  desirable  to  first 
point  out  their  diagnostic  value,  and  afterward  to  discuss  in 
detail  the  individual  affections  one  may  encounter  in  the  ano- 
rectal region. 

The  following  are  the  most  frequent  manifestations  of 
disease  in  this  region : — ■ 

Flatulence  and  tympa- 
nites. 

Abscess  and  fistula. 

Fecal  impaction. 

Dilatation  of  the  rec- 
tum, sigmoid  flexure, 
and  colon. 

Indigestion. 

Change  in  temperature, 
pulse,  and  respiration. 

Odor. 

Color  of  the  skin. 

Induration. 

Altered  condition  of  the 
sphincter-muscles. 


Pain  may  vary  from  a  slight  discomfort  to  the  most  in- 
tense suffering;  it  may  be  constant,  paroxysmal,  local,  or 
reflex.  Again,  its  character  differs  in  the  various  affections: 
it  may  be  sharp,  burning,  lancinating,  dull,  throbbing,  gnaw- 
ing, or  heavy,  sometimes  gradually  changing  from  one  to  the 
other.    As  regards  stool,  it  may  occur  before,  during,  or  after. 

Protrusion. — When  there  is  a  history  of  a  tumor  project- 
ing from  the  anus  it  is  weU  to  ascertain  its  color  and  consist- 
(34)  ,         . 


1. 

Pain. 

16. 

2. 

Protrusions. 

3. 

Hemorrhage. 

17. 

4. 

Constipation. 

18. 

5. 

Diarrhea. 

19. 

6. 

Discharges. 

Itching. 

8. 

Tumors. 

20. 

9. 

Obstruction. 

21. 

10. 

Inflammation. 

11. 

Straining. 

22. 

12. 

Skin  disease. 

23. 

13. 

Altered  feces. 

24. 

14. 

Cachexia. 

25. 

15. 

Auto-intoxication. 

26.  Loss 

of    W( 

SYMPTOMATOLOGY  35 

ence;  whether  it  is  ulcerated,  attached  by  a  pedicle,  returns 
spontaneously,  or  has  to  be  replaced  by  the  patient;  whether 
it  occurs  during  defecation  or  at  irregular  times,  is  of  recent 
origin,  or  of  long  standing;    and,  finally,  whether  it  bleeds. 

Hemorrhage  of  the  rectum  is  one  of  the  most  frequent 
and  dangerous  symptoms  of  rectal  disease.  It  may  be  slight, 
only  a  drop  or  two  streaking  the  feces  in  one  case,  while  in 
another  it  will  be  profuse,  and  the  patient  will  evacuate  enor- 
mous blood-clots  and  pure  blood.  Bleeding  may  be  inter- 
rupted, continuous,  arterial,  or  venous,  and  may  be  excited 
by  defecation.  The  amount  of  hemorrhage  depends  not  only 
upon  the  location  and  extent  of  the  lesion  or  wound,  but  also 
upon  the  nature  and  size  of  the  vessels  involved.  It  is  ag- 
gravated by  coughing,  sneezing,  straining,  and,  in  fact,  by 
anything  which  increases  pressure  in  the  rectum. 

Constipation  is  not  only  a  symptom,  but  also  a  frequent 
cause,  of  rectal  ailments.  The  frequency  of  the  stools  depends, 
to  some  extent,  upon  the  will  and  effort  of  the  patient,  but 
more  often  upon  the  amount  of  obstruction  offered  to  the 
passage  of  the  feces.  An  individual  suffering  from  fissure, 
for  example,  delays  defecation  as  long  as  possible  to  avoid  the 
pain  that  will  ensue.  On  the  other  hand,  a  person  afflicted 
with  stricture  exerts  himself  to  the  utmost  to  empty  the  bowel, 
but  fails  to  do  so  because  of  the  occlusion.  In  some  cases 
defecation  can  be  accomplished  every  two  or  three  days;  in 
others  the  interval  may  be  several  weeks  and  occasionally 
months.  Constipation  is  sometimes  induced  by  hypertrophy 
of  the  sphincter  or  levator  ani  muscles  or  of  Houston's 
"valves."  • 

Diarrhea  is  a  symptom  met  with  in  many  diseases  of  the 
rectum.  It  is  always  prominent  in  stricture,  ulceration,  car- 
cinoma, multiple  polyps,  prolapse,  invagination,  coHtis,  and 
proctitis,  and  sometimes  in  fecal  impaction  and  tuberculosis. 
The  number  and  consistence  of  the  stools  vary  in  the  different 
diseases ;  the  amount  of  straining  and  tenesmus  depends  upon 
the  caliber  of  the  bowel,  extent  of  inflammation,  reaction  of 
the  feces,  and  the  length  of  time  the  latter  are  retained.  The 
number  of  actions  daily  may  range  from  two  or  three  to  a 
hundred,  and  yet  there  may  remain  a  sensation  of  still  more 
to  come  away.  It  is  well  to  inquire  w^hether  the  stools  occur 
with  greater  frequency  at  any  particular  time  of  day;   whether 


36  DISEASES  OF  THE  RECTUM  AND  ANUS 

the  diarrhea  is  made  worse  by  cold,  exercise,  or  kind  of  food 
eaten;  and  whether  the  evacuations  contain  blood,  mucus, 
casts,  pus,  or  undigested  food.  When  all  these  points  are  care- 
fully considered,  they  will  be  invaluable  in  arriving  at  a  correct 
diagnosis. 

Discharges  of  pus,  blood,  mucus,  and  casts  of  the  bowel, 
either  alone  or  admixed,  show  conclusively  the  existence  of 
some  pathologic  condition  of  the  rectum  or  colon.  There  is, 
however,  one  exception  to  this  rule,  namely:  where  there  has 
been  a  hemorrhage  of  the  stomach  the  blood  occasionally  is 
not  ejected  by  the  mouth,  but  passes  into  the  intestines  to  be 
evacuated  in  large,  dark  masses,  and  may  then  be  mistaken 
for  a  hemorrhage  from  the  rectum.  Frequent  and  profuse 
mucous  discharges  are  indicative  of  polyps,  prolapse,  invagi- 
nation, colitis,  or  proctitis,  and,  when  casts  of  the  bowel  are 
present,  they  point  strongly  to  membranous  entero-colo-proc- 
titis.  Mucus  may  be  voided  in  stringy  or  jehy-like  masses. 
Pus  in  the  rectum  may  be  the  result  of  an  abscess,  fistula, 
fissure,  or  ulceration,  either  simple  or  complicating  stricture 
or  carcinoma.  When  thin  and  watery,  the  pathologic  condi- 
tion is  tubercular  or  chronic;  when  thick,  creamy,  and  yellow, 
it  points  to  some  acute  inflammatory  process.  In  chronic  dis- 
eases a  sudden  increase  in  the  amount  of  pus  following  a  rise 
in  the  temperature  is  indicative  of  the  development  of  a  new 
focus  of  infection  and  abscess. 

Pruritis,  or  itching,  in  the  rectum,  at  or  near  the  anus, 
may  be  secondary  to  fissure,  stricture,  parasites,  carcinoma, 
ulceration,  proctitis,  polyps,  chancre,  chancroids,  mucous 
patches,  eczema  marginatum,  or  to  any  disease  of  the  intes- 
tine accompanied  by  an  irritating  discharge  which  oozes  from 
the  anus,  causing  irritation  of  the  skin.  Thread-worms  occa- 
sionally excite  the  most  intense  itching  in  this  region.  It  is 
well  to  bear  in  mind,  however,  that  this  annoying  condition 
is  sometimes  caused  by  gout,  rheumatism,  diabetes  mellitus, 
and  Bright's  disease. 

Tumors,  benign  and  malignant,  occur  with  greater  or  less 
frequency  at  the  anal  margin  and  in  all  parts  of  the  rectum. 
They  may  be  composed  of  muscular,  fibrous,  osseous,  gland- 
ular, or  cartilaginous  tissue,  and  of  firm  or  soft  consistence. 
In  studying  these  growths  it  is  well  to  note  the  age  of  the 
patient,  the  shape  and  duration  of  the  tumor,  whether  there 


SYMPTOMATOLOGY  37 

is  cachexia,  whether  inherited,  and,  finally,  whether  the  neigh- 
boring or  remote  lymphatics  are  involved. 

Obstruction,  partial  or  complete,  may  be  induced  by  strict- 
ure, carcinoma,  benign  tumors,  enteroliths,  foreign  bodies, 
fecal  impaction,  or  congenital  malformation  in  the  rectum. 
Again,  it  may  be  produced  by  enlarged  prostate,  displaced 
uterus,  deformity  of  the  coccyx,  pressure  exerted  from  with- 
out by  any  tumor  which  narrows  the  bowel-caliber,  and  by 
hypertrophy  and  thickening  of  Houston's  "valves." 

Inflammation  confined  to  the  mucous  membrane  or  ex- 
tending to  the  muscular  coat  and  perirectal  tissues  may  be  a 
symptom  of  certain  rectal  affections  and  injuries.  It  is  started 
usually  by  some  irritant  taken  with  the  food,  as  a  fish-bone; 
or  by  a  blow  or  kick;  the  passage  of  hard,  nodular,  fecaloid 
tumors ;  purgatives ;  frequent  medicated  enemata ;  operations 
or  irritating  discharge  from  some  more  serious  disease  higher 
up  the  bowel,  or  it  rnay  result  from  fermentative  changes  and 
bacterial  action  when  the  feces  are  retained  in  the  rectum  for 
a  considerable  time. 

Straining  is  a  symptom  of  prominence  in  many  rectal  ail- 
ments :  fecal  impaction,  obstruction  from  tumors,  exaggerated 
retroversion  of  the  uterus,  stricture,  Tilceration,  and  proctitis. 
It  may  be  continuous  or  interrupted,  depending  upon  the  com- 
pleteness of  the  occlusion,  the  irritant  qualities  of  the  discharge, 
and  the  consistence  of  the  feces. 

Skin  Disease  is  seldom  met  with  in  the  anal  region ;  per- 
haps the  most  common  manifestations  of  this  kind  are  tuber- 
culosis, marginal  eczema,  congenital  syphilis,  erosions  caused 
by  a  rectal  discharge,  condylomata,  chancres,  and  chancroids. 

Altered  Feces  are  an  important  symptom,  and  much  can  be 
learned  from  a  careful  study  of  their  shape  and  consistence. 
When  long,  ribbon,  tape-like,  or  small  and  round,  a  stricture 
should  be  suspected,  especially  when  there  is  a  tendency  to 
frequent  stools  and  straining.  Other  affections  which  may 
induce  like  symptoms  are  abnormally  developed  Houston 
"valves,"  carcinoma,  extensive  ulceration,  proctitis,  polyps, 
prolapse,  and  congenital  malformations  (narrowing)  of  the  rec- 
tum and  anus.  The  author  has  more  than  once  observed  the 
passage  of  normal-sized  stools  by  persons  suffering  from  a 
fight  stricture,  in  whom  the  liquid  or  semisolid  feces  escaped 
into  the  rectum  below  the  constriction,  where  they  remained 


38  DISEASES  OF  THE  RECTUM  AND  ANUS 

until  the  watery  portion  was  absorbed,  and  were  then  voided, 
natural  in  consistence,  shape,  and  size. 

Cachexia  is  a  reliable  symptom  of  rectal  carcinoma  in  the 
middle  and  last  stages  of  the  disease  and  occasionally  in  tuber- 
culosis of  the  rectum. 

Auto-intoxication  sooner  or  later  manifests  itself  in  cases 
of  chronic  constipation,  chronic  diarrhea,  and  in  other  affec- 
tions where  the  denuded  bowel  permits  pathogenic  bacteria, 
especially  the  colon  bacillus,  to  enter  the  circulatory  systems. 

Flatulence  and  Tympanites  are  present  in  most  chronic  rec- 
tal disorders.  The  former  is  always  a  symptom  of  fissure  and 
constipation,  and  particularly  of  intestinal  indigestion;  the 
latter  of  stricture  and  malignancy,  becoming  marked  when 
perforation  takes  place. 

Abscess  and  Fistula  may  be  symptoms  of  any  pathologic 
condition  accompanied  by  ulceration  and  the  formation  of 
pus;  this  is  especially  true  when  the  latter  does  not  have  a 
free  exit.  Again,  they  are  sometimes  the  sequels  of  an  opera- 
tion in  which  due  regard  has  not  been  given  to  asepsis,  and 
also  of  a  foreign  body  occupying  the  rectum. 

Fecal  Impaction  is  frequently  induced  by  constipation, 
stricture,  tumors,  and  any  affection  causing  intestinal  occlu- 
sion. It  is  a  symptom  of  rectal  disease  which  should  not  be 
ignored. 

Dilatation  of  the  Rectum,  Sigmoid  Flexure,  and  Colon  is  not  an 
uncommon  complication  of  diseases  in  the  terminal  colon.  It 
is  usually  a  symptom  of  some  pathologic  condition  which  pro- 
duces fecal  accumulation  and  impaction.  The  bowel  becomes 
at  times  enormously  dilated,  displacing  the  neighboring  viscera 
and  organs. 

Indigestion,  the  result  of  reflex  irritation,  impairment  of 
intestinal  digestion,  and  assimilation,  is  frequently  a  symptom 
of  ulceration,  stricture,  and  carcinoma  of  the  rectum. 

Temperature,  Pulse,  and  Respiration,  one  or  all,  may  vary 
from  the  normal  in  certain  diseased  conditions  of  the  rectum 
and  sigmoid  as  the  result  of  exhaustion,  auto-intoxication, 
and  acute  infection. 

The  Odors  emanating  from  certain  rectal  discharges  are 
extremely  unpleasant,  and  are  often  characteristic  of  the  dis- 
ease. The  odor  coming  from  cancer,  gonorrhea,  and  syphilitic 
condylomata  is  typic,  and,  once  inhaled,  will  be  remembered. 


SYMPTOMATOLOGY  39 

The  Color  of  the  Skin,  when  red,  points  to  acute  processes; 
when  bluish  in  tint,  to  some  chronic  affection,  especially  tu- 
berculosis ;   and  when  dark,  to  an  acrid  discharge. 

Induration  about  the  anus  is  a  symptom  of  an  old  fistula, 
the  beginning  of  an  abscess,  or  chronic  inflammation. 

The  Condition  of  the  Sphincter  is  sometimes  a  valuable  symp- 
tom. A  tight  muscle  indicates  an  acute  condition,  and  a  patu- 
lous one  a  serious  and  chronic  afifection. 

Loss  of  Weight  points  to  malignant  or  to  tubercular  dis- 
ease or  to  some  affection  of  the  rectum  accompanied  by  fre- 
quent and  copious  hemorrhages,  the  discharge  of  considerable 
pus,  great  straining,  or  diarrhea. 


40 


DISEASES  OF  THE  RECTUM  AND  ANUS 


CHAPTER  IV 

EXAMINATION 

Having  pointed  out  the  diagnostic  value  of  the  symptoms 
manifested  by  disease  in  the  colon,  sigmoid  flexure,  rectum, 
and  anus,  it  now  remains  to  describe  the  various  procedures 
resorted  to  in  the  examination  of  these  parts.  A  careful  study 
should  be  made  of  each  case,  nothing  being  taken  for  granted 
even  where  the  diagnosis  has  already  been  made  by  the  pa- 
tient or  his  family  physician.  It  is  true  that  a  rectal  examina- 
tion is  repugnant  to  both  patient  and  physician,  yet  this  is  no 
excuse  for  making  a  slipshod  diagnosis. 

In  making  an  examination,  it  is  desirable  to  expose  the 
parts  as  little  as  possible,  and  also  to  be  very  gentle  in  the 
introduction  of  the  finger  and  instruments  into  the  bowel.  The 
amount  of  suffering  induced  by  exploration  frequently  decides 
whether  the  patient  will  submit  to  an  operation  or  not,  for, 
A^hen  pain  is  severe,  many  become  discouraged,  believing  that 
the  operation  would  be  unbearable.  On  the  other  hand,  any 
surgeon  who  prescribes  for  a  patient  without  first  ascertaining 
the  exact  nature  of  his  ailment  is  guilty  of  negligence,  and  de- 
serves to  forfeit  the  confidence  of  the  one  he  is  treating.  In 
the  past  there  was  some  excuse  for  a  mistaken  diagnosis  when 
the  disease  was  located  in  the  upper  rectum  and  sigmoid  flex- 
ure. To-day,  by  means  of  modern  instruments  and  a  better 
knowledge  of  anatomy,  disease  in  these  regions  can  be  located 
with  ease  and  accurately  diagnosticated. 

PREPARATION  FOR  EXAMINATION 

To  make  a  thorough  examination  it  is  necessary  to  have 
the  sigmoid  flexure  and  rectum  completely  emptied  of  fecal 
matter.  It  is  always  disagreeable  and  frequently  impossible 
to  arrive  at  a  correct  diagnosis  unless  this  has  been  done.  If 
the  patient  has  not  been  seen  previously  and  desires  an  early 
examination,  the  bowel  should  be  cleansed  immediately  with 
one  or  more  soap-suds  enemata.     When  there  is  no  hurry,  a 

(41) 


42 


DISEASES  OF  THE  RECTUM  AND  ANUS 


reliable  cathartic  should  be  administered  the  day  before,  and 
a  small  enema  given  just  prior  to  the  examination.  In  order 
to  prevent  annoyance  any  water  remaining  in  the  bowel  should 
be  removed  by  means  of  the  rectal  evacuator,  described  else- 
where. Occasionally  it  is  necessary  to  determine  whether  a 
fecal  accumulation  is  located  in  the  upper  or  lower  rectum; 
and,  if  so,  its  effect  upon  the  sphincter  and  levator  ani  muscles; 
whether  pain  or  protrusion  are  caused  by  it  and  whether  it  is 
liquid,  soft,  firm,  or  nodular.  This  can  be  accomplished  by 
digital  examination  alone,  and  before  the  rectum  has  been 
cleansed. 


Fig.  7.— Allison  Office  and  Operating  Table. 


INSTRUMENTS   FOR   EXAMINATION 

The  instruments  necessary  for  the  proper  examination  of 
the  terminal  colon  are  few,  but  rather  expensive.  The  follow- 
ing are  indispensable  to  the  proctologist: — 

5.  Proctoscopes  and  colon- 
oscopes. 

6.  Probes. 

7.  Graduated  bousfies. 


1.  Table. 

2.  Light. 

3.  Head  and  reflecting  mir- 

rors. 

4.  Small  speculum. 


8.  Aspirating  needle. 


Table. — A  table  suitable  for  rectal  examination  should  be 
strong,  and  not  less  than  eighteen  inches  (20.3  centimeters) 
in  width.  It  should  be  so  constructed  that  either  end  can  be 
raised,  lowered,  or  tilted  from  side  to  side,  and  should  be  of 
sufficient  height  to  enable  the  eyes  of  the  examiner,  while  the 
latter  is  sitting,  to  remain  on  a  level  with  the  anus  when  the 


EXAMINATION 


43 


patient  is  in  Sims's  position.  The  table  built  by  the  W.  D. 
Allison  Company  (Fig.  7)  meets  all  these  requirements,  and 
can  be  used  for  operations  if  necessary.  Their  office  cabinet 
(Fig.  8)  is  also  a  convenient  and  useful  piece  of  office  furniture. 
Suitable  Light. — The  author  has  spent  much  time  and 
money  experimenting  with  lights  devised  for  illuminating  the 
rectum.  In  some  the  light  was  carried  into  the  bowel;  in 
others  it  was  reflected  by  the  aid  of  a  head-mirror  or  spe- 
cially constructed  reflector.  The  lights  experimented  with 
have  been  electric  (Figs.  10  and  11),  gasoline,  acetylene-gas, 


Fig.   8. — Allison's   Office   Instrument   Cabinet. 

candle,  and  ordinary  gas,  with  and  without  the  Welsbach 
burner.  For  all  purposes,  gas-light  (without  the  Welsbach 
burner)  reflected  by  a  head-mirror,  and  coming  from  a  lamp 
with  a  bull's-eye  reflector  capable  of  being  adjusted  to  the 
proper  position,  has  proven  satisfactory.  This  light  is  suffi- 
ciently strong,  steady,  easy  to  control,  and  equally  suitable  for 
examination  of  the  anus  and  sigmoid  flexure.  The  ordinary 
electric  bulb  fitted  with  a  reflector,  or  the  small  lamp  attach- 
ment with  the  proctoscope,  are  the  most  convenient  and  satis- 
factory methods   of   direct   illumination   for  office   use.      Gaso- 


44 


DISEASES  OF  THE  RECTUM  AND  ANUS 


line-light  has  no  advantage  over  gas,  candle-light  is  too  dim, 
and  acetylene-light  is  difficult  to  control  and  is  accompanied 
by  a  foul  odor.  Whatever  light  is  used,  it  should  be  supported 
by  a  number  of  jointed  arms  in  order  to  facilitate  adjustment 
to  any  desired  position  (Fig.  12)  without  moving  the  patient. 
Head  and  Reflecting  Mirrors. — Such  mirrors  of  suitable  sizes 
are  essential  to  the  proctologist.  They  are  especially  useful 
in  the  examination  of  the  upper  rectum  and  for  locating 
fistulas  and  abrasions  near  the  anus.     The  reflecting  mirrors 


Fig.  9. — Martin's  Modification  of  the  Yale  Chair  for  the  Proctoscopy  Posture. 
Adjustable  Illumination  Apparatus.     Small  Pillow  and  Shoulder-strap. 


should  be  of  such  a  size  as  to  pass  readily  through  the  proc- 
toscope ;  the  handles  should  be  long,  and  bent  at  a  right 
angle  so  as  to  avoid  obstructing  the  view. 

Specula. — The  choice  of  a  rectal  speculum  is  not  of  so 
much  importance  as  the  junior  proctologist  believes.  The 
experienced  rectal  specialist  depends  more  upon  the  procto- 
scope and  digital  examination  than  upon  the  speculum.  In 
order  to  be  easily  introduced  specula  should  be  constructed  to 
represent,  as  near  as  possible,  the  size  and  shape  of  the  index 
finger.     They  should  also  have  a  flange  to  keep  the  buttocks 


EXAMINATION 


45 


from  obstructing  the  view  and  expose  only  one  side  of  the 
bowel  at  a  time.  The  speculum  should  never  be  introduced 
until  the  rectum  has  first  been  prepared  for  it  by  digital  ex- 
amination, and  it  should  never  be  revolved  while  in  the  bowel ; 
on  the  contrary,  it  should  be  reintroduced  for  the  examination 
of  each  side  of  the  rectum.  The  one  used  by  the  author  was 
devised  by  him  some  time  ago  (Fig.  13),  and  thus  far  has 
proven  entirely  satisfactory.  This  instrument  is  suitable  for 
examinations  of  the  lower  three  inches  (7.6  centimeters)  of 
the  rectum  only.  When  it  is  desirable  to  examine  the  upper 
rectum  the  proctoscope  should  be  used. 


Fig.  10. — Battery  and  Little  Wonder  Electric  Light. 


Proctoscopes  and  Colonoscopes.  —  Until  the  advent  of  these 
instruments,  practically  no  attempt  was  made  to  locate  disease 
in  the  upper  rectum  and  sigmoid  flexure.  Now  foreign  bodies 
and  disease,  ulceration,  carcinoma,  polyps,  stricture,  fistulas, 
and  proctitis  in  these  parts  can  be  located  and  diagnosticated 
just  as  accurately  as  affections  of  the  naso-pharynx.  Soon  after 
Marion  Sims,  in  1845,  demonstrated  the  inflatability  of  the 
vagina,  rectal  surgeons  set  about  applying  the  same  principle 
to  the  rectum.  Bodenhamer,  Van  Buren,  Allingham  (Sr.), 
Cooper,  and  Otis  were  the  pioneers  in  this  work.  In  recent 
years  Kelly,  Martin,  Law,  Pennington,  Tuttle,  and  Beach  have 
done  good  work  in  popularizing  this  method  of  examination, 


46 


DISEASES   OF  THE   RECTUM  AND  ANUS 


and  have  devised  proctoscopes  and  colonoscopes  (Figs.  19 
to  25)  of  practical  utility.  Bodenhamer  was  the  first  to  devise 
an  instrument  of  this  type,  called  the  redo-colonic  endoscope 
(Fig.  24),  through  which  the  rectum  and  sigmoid  could  be  ex- 
amined by  the  aid  of  reflected  light.  It  is  described  and  illus- 
trated in  his  most  excellent  little  book :  "The  Physical  Ex- 
ploration of  the  Rectum,"  published  in  1870. 

The  ends  of  the  Laws,  Pennington,  and  Beach  procto- 
scopes are  closed  with  glass  caps  through  which  the  operator 
looks  while  the  rectum  is  kept  inflated  by  means  of  a  tube  and 
rubber  bulb.  Tuttle's  proctoscope  differs  from  the  instruments 
just  described  in  that  the  electric  lamp  when  soiled  must  be 


Fig.   U.— Little  Wonder  Electric  Light  in   Position. 


withdrawn  in  order  to  cleanse  it;  he  uses  a  plug  containing 
a  magnifying  glass  to  close  his  proctoscope,  and  this,  he  claims, 
blows  out  under  strong  pressure  and  thereby  eliminates  the 
danger  of  rupturing  the  bowel.  The  author  is  of  the  opinion 
that  instruments  of  this  type  will  not  come  into  general  use, 
for  the  reason  that  a  closed  tube  is  not  necessary  to  accomplish 
inflation  of  the  rectum,  they  are  expensive,  and,  further,  be- 
cause a  film  of  condensed  moisture  sometimes  forms  on  the 
glass  and  obstructs  the  view. 

Tuttle  has  also  modified  the  Kelly  tube  so  that  the  ob- 
turator gives  to  its  end  a  Mercier  curve,  which  is  supposed  to 
lessen  the   difficulty  in  rounding  the   sacral   promontory  and 


EXAMINATION 


47 


entering  the  sigmoid.  The  Martin  proctoscope  (Fig.  25)  is 
made  in  two  sizes  (examining  and  operating)  and  of  different 
lengths. 

Proctoscopes  and  colon-tubes  should  contain  an  obturator. 
Force  should  never  be  used  in  their  introduction,  otherwise 
there  is  danger  of  rupturing  the  bowel.  The  author  has  had 
one  such  accident,  and  others  have  been  equally  unfortunate. 
The  rupture  usually  occurs  in  the  sigmoid  flexure,  between  its 
two  fixed  points.  The  proctoscope  and  the  knee-chest  posture 
are  essential  when  the  rectum  and  sigmoid  are  to  be  inflated 
for  examination  and  operation  without  the  aid  of  a  hand-bulb. 

Probes. — Probes  of  various  sizes  are  necessary  in  examin- 
ing for  fistulas  and  necrosed  bone,  to  measure  the  depth  of 
ulcers,  and  to  ascertain  whether  their  edges  are  undermined. 


Fig.  12. — Gant's  Artificial  Light,  Table,  and  Irrigating  Apparatus. 


Bougies. — Graduated  bougies  are  serviceable  in  determin- 
ing the  size  of  rectal  strictures  and  their  distance  from  the  anus. 
They  should  never  be  used  blindly,  but  their  introduction 
should  always  be  preceded  by  the  insertion  of  the  proctoscope. 
When  the  constriction  comes  into  view,  the  measurements  can 
be  accurately  made,  the  extent  of  the  occlusion  noted,  and  a 
bougie  of  proper  size  selected.  Force  must  always  be  avoided 
in  the  introduction  of  a  bougie. 

Aspirating  Needle.  —  An  aspirating  needle  is  occasionally 
useful  in  revealing  the  exact  nature  of  the  fluid  contained  in 
cysts  and  fluctuating  tumors  situated  in  and  near  the  rectum. 
Their  promiscuous  use,  however,  is  to  be  deprecated. 


48 


DISEASES  OF  THE  RECTUM  AND  ANUS 


POSITION   OF   THE   PATIENT 

The  most  satisfactory  positions  for  examining  the  outer 
parts  and  lower  rectum  are  the  semiprone,  of  Sims,  and  the 
hthotomy  postures.  For  examination  of  the  upper  rectum  and 
sigmoid  flexure,  where  inflation  is  desired,  the  genu-pectoral 
or  Martin's  (Fig.  26)  is  best.  It  must  be  remembered,  how- 
ever, that  in  certain  cases — such  as  chronic  proctitis,  strict- 
ure, and  cancer,  where  the  rectal  walls  are  much  thickened  or 
bound  down  by  adhesions — inflation  is  impossible.  When  there 
are  indications  pointing  to  the  presence  of  a  tumor  in  the 
upper  rectum,  and  it  cannot  be  located  with  the  patient  in  the 


Fig.  13.— Gant's  Office  Speculum. 

above  position,  he  should  be  requested  to  stand  with  his  legs 
well  apart  and  bear  down  as  the  finger  is  passed  upward.  In 
this  way  an  extra  two  inches  (5  centimeters)  are  gained,  and 
the  tumor  may  be  located. 

The  lithotomy  posture  (Fig.  27)  is  the  most  desirable 
for  rectal  examination  when  the  patient  is  under  the  influence 
of  an  anesthetic,  and  the  recumbent  posture  when  the  abdom- 
inal and  pelvic  viscera  are  to  be  examined.  The  Trendelenburg 
position  is  sometimes  of  service  in  doubtful  cases. 


ANESTHESIA 

In  most  cases  an  anesthetic  is  unnecessarv  when  reason- 


able care  is  exercised. 


When  general  anesthesia  is  desired, 


EXAMINATION 


49 


ether  or  chloroform  ma)^  be  used.  Many  patients  do  better 
under  the  former  when  it  is  preceded  by  the  administration  of 
laughing-gas.     Chloroform  is  preferable  in  tubercular  subjects 

The  best  local  anesthetics  are  sterile  water,  cocaine  (4  per 
cent),  and  beta-eucaine  (3  per  cent.)  applied  to  or  injected 
around  the  part  to  be  examined.  When  the  anal  outlet  is  ex- 
tremely sensitive,  suffering  may  be  lessened  by  freezing  it  with 
the  ether-spray,  with  kelene  (ethyl  chloride),  or  liquid  air. 

Digital  Examination.  —  Much  valuable  information  can  be 
obtained  by  introduction  of  the  educated  finger  into  the  bowel 


Fig.   14.— Cook's  Trivalved  Operating  Speculum. 


(Fig.  29).  Hemorrhoids,  fecal  impaction,  foreign  bodies, 
tumors,  fissures,  ulcers,  carcinoma,  polyps,  thickening  of  the 
bowel-wall  from  whatever  cause,  strictures,  and  fistulous  open- 
ings, when  in  the  lower  rectum,  are  easily  located  by  tactile 
examination.  The  nail  should  be  pared,  the  finger  oiled  with 
som.e  stiff  lubricant  such  as  vaselin  and  passed  slowly  through 
the  anus  with  a  boring  motion.  When  the  sphincter  contracts, 
a  few  seconds  should  be  allowed  for  relaxation  to  take  place ; 
the  examination  may  then  be  continued  by  sweeping  the  finger 
around  the  bowel,  first  in  one  direction  and  then  in  another. 
The  condition  of  the  sphincter,  surface  of  the  mucosa,  pros- 


50 


DISEASES  OF  THE  RECTUM  AND  ANUS 


tate  gland,  uterus,  bladder  and  vaginal  septum,  sacrum,  and 
coccyx  should  be  noted. 

With  the  index  finger  in  the  rectum,  by  pressing  against 
the  perineum  with  the  thumb  and  against  the  post-anal  struct- 
ures with  the  other  three  fingers  an  additional  inch  (2.54  centi- 
meters) of  bowel  may  be  brought  into  the  field  of  examination. 

Eversion  of  the  Anus  and  Rectum. — In  women  the  lower  rec- 
tum is  easily  everted  by  placing  two  fingers  in  the  vagina  and 
pushing  the  bowel  downward.  In  this  way  pathologic  condi- 
tions near  the  anus  may  be  brought  into  view  without  the  aid 
of  the  speculum.  Fissures,  mucous  patches,  ulcers,  and  other 
affections  located  near  the  anal  margin  can  be  seen  by  placing 
the  thumb?  on  either  side  of  the  anal  aperture  and  requesting 


Fig.  15. — Hinged  Speculum 


the  patient  to  bear  down  as  the  buttocks  are  pulled  apart,  thus 
everting  the  anus. 

Vaginal  Examination. — By  this  procedure  the  condition  of 
the  recto-vaginal  septum,  uterus,  vagina,  and  bladder,  and  the 
consistency,  size,  and  shape  of  rectal  tumors,  impactions,  and 
strictures,  may  be  ascertained. 

Palpation. — This  method  of  examination  is  a  valuable  ad- 
junct in  tracing  fistulous  sinuses,  locating  abscesses,  tumors, 
and  tender  spots  in  the  anal  region.  Palpation  of  the  abdomen 
and  pelvis  frequently  enables  one  to  locate  an  obstruction, 
tumor,  impaction,  or  abscess  in  the  pelvis,  upper  rectum,  or 
sigmoid  which  could  not  be  made  out  from  below. 

Percussion  and  Fluctation  assist  in  locating  tumors,  detect- 
ing fluids,  and  determining  the  extent  of  dilatation  of  the  colon 
in  cases  of  partial  and  complete  occlusion. 


EXAMINATION 


51 


Succussion. — Bouchard  has  emphasized  the  value  of  this 
method  in  determining  the  amount  of  gas  and  hquid  in  the 
bowel.  With  the  patient  in  the  recumbent  position,  a  series 
of  rapid  taps  are  made  over  the  sigmoid  and  colon.  If  the 
bowel  contains  a  large  amount  of  gas  and  liquid,  their  presence 
is  revealed  by  a  sensation  of  splashing. 

Distension. — Distension  of  the  bowel  with  fluid  or  gas  is 
sometimes  of  assistance  in  doubtful  cases  (especially  invagina- 
tion) where  a  diagnosis  is  to  be  reached  by  exclusion. 

Exploratory  Incision  should  be  resorted  to  in  all  cases  of 
suspected  disease  in  the  upper  rectum,  sigmoid  flexure,  and 
colon  where  diagnosis  is  impossible  by  less  radical  procedures. 

Introduction  of  the  Hand  into  the  bowel  for  the  purpose  of 
examining  the  rectum  is  dangerous,  barbarous,  and  entirely  un- 


Fig.  16. — Pratt's  Bivalved  Operating  Speculum. 


called  for.  Formerly  there  was  some  excuse  for  resorting  to 
this  method  of  examination,  but  since  the  advent  of  the  proc- 
toscope there  is  none.  Several  deaths  have  followed  rupture 
of  the  intestine  caused  by  insertion  of  the  hand  into  the  rectum. 

Inspection.  —  No  examination  is  complete  until  the  anus 
and  vicinity  have  been  thoroughly  inspected.  Pruritus,  ec- 
zema, primary  tuberculosis,  condylomata,  chancres,  chancroids, 
fissures,  congenital  syphilis,  and  thread-worms  can  usually  be 
recognized  in  this  way  without  internal  examination. 

Urine  and  Blood. — The  urine  and  blood  in  all  grave  cases 
and  of  persons  who  are  to  undergo  a  tedious  operation  should 
be  examined  to  ascertain  the  condition  of  the  kidneys  and 
proportion  of  the  blood-corpuscles.  When  the  count  goes  be- 
low 1,000,000  it  means  pernicious  anemia.  Leucocytosis  almost 
invariably  accompanies  exudative  inflammation,  and  is  present 


53  DISEASES  OF  THE  RECTUM  AND  ANUS 

in  acute,  chronic,  deep,  superficial,  encapsulated,  or  diffuse  sup- 
puration. It  occurs  in  malignancy,  and  the  absence  of  leuco- 
cytosis  in  uncomplicated  cases  is  indicative  of  gall-stones,  fecal 
impaction,  obstruction,  and  neuralgia  (Coey).^. 

Intestinal  Discliarg-es  can  be  inspected  with  either  the  un- 
aided or  aided  eye.  Inspection  frequently  supports  a  diagnosis 
based  upon  other  clinical  signs,  and  sometimes  it  is  the  only 
means  by  which  a  decision  can  be  reached. 

EXAMINATION    OF   THE   FECES  2 

Macrosccpic  Examination  shows  the  following :  The  feces  of 

a  healthy  individual  are  light  or  dark  brown  in  color,  cylindric 
in  form,  firm  in  consistence,  and  usually  alkaline  in  reaction. 


Fig.   17.— Mathews's  Rectal  Speculum. 


In  children,  because  of  the  large  amount  of  milk  composing 
their  diet,  the  color  is  Hght  yellow;  in  healthy  adults,  also,  the 
stools  may  become  dark  brown  or  black  through  the  agency 
of  foods  (red  wine,  huckleberries)  and  medicines  (iron,  bismuth 
subnitrate,  through  the  sulphur  compounds  formed  by  them). 
The  dejecta  are  colored  yellow  after  ingestion  of  rhubarb,  san- 
tonin, and  senna,  and  green  after  calomel.  The  normal  fecal 
casts  usually  show  fissures  and  indentations,  which  indicate 
their  formation  from  individual  scybala.  Not  infrequently  the 
alvine  discharge  appears  in  the  form   of  masses  resembling 


1  St.  Paul  Medical  Journal,  October  27,  1900. 

2  In   the  preparation   of  this   article   the   treatise   of  Lenhartz — "Mikroskopie   und 
Chemie  am  Krankenbett" — has  been  freely  drawn  upon. 


EXAMINATION  53 

sheep-manure,  without  the  existence  of  any  pathologic  altera- 
tion of  the  intestine. 

In  disease  of  the  intestine  the  quantity,  form,  and  color 
of  the  feces  may  be  decidedly  altered.  Instead  of  a  single 
stool  usually  amounting  to  100  to  200  grams  (3.2  to  6.4 
ounces),  the  dejections  may  be  very  frequent — 10  to  20 — and 
amount  to  as  much  as  1000  grams  (32  ounces).  The  cylin- 
dric  form  disappears;  the  stool  becomes  mushy,  pap-Uke,  or 
watery.  Undigested  remnants  of  food  (fragments  of  potato, 
vegetables,  etc.)  can  be  recognized  with  the  naked  eye  in  the 
sometimes  light-colored,  sometimes  darkly-stained  evacuations 
(see  page  31). 

In  biliary  congestion  the  stools  are  grayish  yellow  or  clay- 
like;   in  obstinate   constipation  they  are  deep  brown  or  black 


Fig.  IS. — Sims's  Wire  Speculum. 

(so-called  carbonized  stool).  In  hemorrhage  into  the  lower 
portion  of  the  intestine  fresh  blood  may  be  passed  with  the 
dejecta;  when  the  point  of  bleeding  is  located  higher  up,  the 
stools  are  usually  strikingly  altered:  dark  brown  to  tar  col- 
ored. The  latter  color  is  present  in  stools  following  gastric 
hemorrhage.  In  cholera  rice-water,  or  soup-like,  evacuations 
occur:  in  many  forms  of  enteric  catarrh  (especially  in  children) 
the  stools  are  gall  or  grass-green  colored. 

While  occasional  mucous  shreds  or  flocculi  are  observed 
in  the  stools  of  healthy  individuals  only  when  the  feces  are 
very  hard  and  firm,  large  mitcoiis  sJireds  are  often  mixed  with 
thin  dejecta,  or  large  gelatinous  mucous  masses  are  expelled 
with  or  without  feces  (colitis,  cholera,  dysentery,  etc.).  Now 
and  then  tenacious  glassy  mucus  may  adhere  to  a  single  firm 
stool  (catarrh  of  lower  colon  and  rectum),  or  long-ribbon-like 


54 


DISEASES  OF  THE  RECTUM  AND  ANUS 


or  tubular-formed  mucous  coagula  are  discharged  with  the 
stools  (see  "Enteritis  Membranacea,"  page  64). 

Sago-like  bodies,  the  vegetable  origin  of  which  can  be 
determined  by  the  microscope,  may  be  mistaken  for  mucous 
masses. 

The  usually  alkaline  reaction  of  the  feces,  which,  however, 
not  infrequently  changes  in  healthy  individuals,  may  become 
acid,  especially  in  children  suffering  from  acute  catarrhal  en- 
teritis. The  reaction  is  of  no  diagnostic  significance.  The 
well-known  "fecal  odor"  becomes  in  many  diseases  stinking 
putrid  (cancer,  etc.)  or  disappears  entirely  (dysentery). 


Fig.  19. — Kelly's  Colonoscope,  Proctoscope,  and  Anoscope. 


In  addition  to  many  foreign  bodies,  small  or  large  gall- 
stones and  worms  and  their  ova  (see  page  59)  may  appear  in 
the  dejecta  and  be  of  valuable  diagnostic  significance. 

Bile-concrements  occur  in  the  feces  as  true  stones  the  size 
of  a  pigeon's  egg  and  larger,  or  in  the  form  of  gravel.  In 
order  to  detect  the  smaller  stones  it  is  necessary  to  sift  and 
wash  the  feces.  The  stones  sometimes  have  a  polygonal, 
sometimes  tablet  form ;  are  usually  soft  and  of  a  yellowish- 
gray-white  or  brown  color.  They  are  sometimes  homoge- 
neous, and  on  fracture  present  a  distinctly-crystalline  surface, 
or  they  are  of  composite  formation,  presenting  a  dark  nucleus, 
radiate  lamellas,  and  a  sometimes  smooth,  white,  or  greenish, 


EXAMINATION 


55 


sometimes  a  roughened,  grayish-black  cortex.  Cholesterin  and 
bilirubm-calcium  are  the  chief  constituents  of  the  stones.  The 
rare  pure  cholesterin  calculi  are  pure  white  or  yellowish  white, 
usually  smooth,  translucent,  and  sometimes  show  a  glistening, 
pearly  surface,  owing  to  superficial  deposits  of  cholesterin 
crystals.  The  much  more  common  cholesterin-bilirubin  stones 
are  sometimes  yellow  or  dark  brown,  sometimes  greenish 
brown,  and  also  usually  have  a  smooth  surface.  Calcium-car- 
bonate calculi,  on  the  other  hand,  are  often  roughened. 

Gall-stones  are  of  much  (four  to  five  times)  more  frequent 
occurrence  in  women  than  in  men,  and  particularly  in  women 
who  have  borne  children.  They  are  quite  rare  up  to  the 
thirtieth  year,  more  frequent  after  thirty,  and  very  frequent  in 


Fig.  20.— Kelly's  Proctoscope  with  Electric-Light  Attachment. 


people  over  sixty  years  of  age.  A  desquamative  angiocolitis 
is  the  primary  disturbance. 

Microscopy  of  the  intestinal  discharges  is  very  repulsive, 
and  in  many  cases  can  be  accomplished  only  under  observance 
of  certain  precautions.  The  latter  include  not  only  the  pre- 
ventive measures  indicated  to  avoid  danger  from  infection,  but 
also  those  aids  which  are  rendered  necessary  by  the  intolerable 
stench.  In  the  case  of  thin  stools  it  is  advisable  to  cover  the 
specimen  of  feces  in  a  conic  glass  with  a  layer  of  ether.  In 
this  way  the  odor  is  greatly  diminished.  For  examination 
some  of  the  sediment  in  the  conic  glass  is  either  taken  at 
random  with  a  pipette,  or  some  definite  portion  distinguishable 
to  the  naked  eye  is  selected.  On  other  occasions  some  of  the 
stool  is  spread  upon  a  plate  and  examined  for  certain  objects. 

Under  normal  conditions  there  will  be  found: — 


56 


DISEASES  OF  THE  RECTUM  AND  ANUS 


1.  Food-remnants.  — Muscle-fibers,  recognizable  by  distinct 
transverse  striations,  are  sparingly  found;  starch-remnants 
very  seldom;  more  frequently  plant-cells  of  salad,  spinach, 
and  fruits ;  milk-remnants  in  the  form  of  yellow- white  flocculi ; 
finally,  fat,  more  in  crystalline  than  in  globule  form. 

2.  Crystals  and  Salts. — Triple  phosphate,  in  coffin-lid  form, 
and  large  and  small  rosettes  of  neutral  calcium  phosphate  are 
of  most  frequent  occurrence;  much  rarer  calcium  oxalate  (in 
envelope  form)  (Fig.  31).  Lime-salts,  which  are  stained  yellow 
with  bile  coloring  matter  and  give  the  well-known  reaction  on 


Fig.  21. — Laws's  Proctoscope. 


addition  of  nitric  acid,  are  frequent.     Cholesterin  crystals  (Fig. 
32)  are  much  rarer. 

3.  Epithelial  Cells  are  usually  absent;  a  few  cells  are  me- 
chanically dislodged  only  from  the  squamous-celled  covering 
of  the  lower  rectum  by  the  passage  of  firm  feces. 

4.  Bacteria  occur  in  large  numbers  in  every  stool.  Be- 
sides elliptic  yeast-cells,  which  are  usually  of  a  yellow  tint,  and 
the  long,  motile  rods  and  large  masses  of  the  bacillus  subtilis, 
many  forms  of  cocci  and  bacilli,  which  stain  blue  when  treated 
with  Lugol's  solution,  are  deserving  of  attention,  among  others 


EXAMINATION 


57 


the  cJilostridiiim  butyriciun,  thoroughly  investigated  by  Noth- 
nagel.  This  organism  appears  in  the  form  of  broad  rods  with 
rounded  ends  or  as  elHptic  or  spindle-shaped  bodies.  The 
size  as  well  as  the  arrangement  varies.  They  occur  singly  or 
in  the  form  of  zooglese.  When  treated  with  Lugol's  solution 
they  are  stained  blue  or  violet  in  toto  or  only  in  their  central 
portions.  In  vegetable  diet  they  are  much  more  numerous 
than  upon  a  proteid  one.  As  Brieger  has  shown,  they  give 
rise  to  butyric-acid  fermentation. 

In  pathologic  states  of  the  intestine  microscopy  shows : — 


Fig.  22.— Method  of  Using  Various  Instruments  Through  the  Laws  Proctoscope. 


Aside  from  the  admixtures  of  undigested  food  which  are 
macroscopically  recognizable  in  severe  disturbances,  micro- 
scopic examination  shows  in  milder  cases  a  considerable  in- 
crease of  muscle-fibers  and  the  appearance  of  undissolved  starch, 
which  otherzvise  is  rarely  present.  Its  abundant  occurrence  points 
to  the  existence  of  serious  catarrh.  Furthermore,  casein,  fat, 
and  triple  phosphates  are  present  in  large  quantity.  Choles- 
terin  and  hematoidin  crystals  are  usually  of  rare  occurrence. 
Delicate  octahedra,  morphologically  and  chemically  resembhng 
Charcot-Leyden  crystals,  are  decidedly  more  frequent.     In  ad- 


58 


DISEASES  OF  THE  RECTUM  AND  ANUS 


dition  to  typhoid,  dysentery,  and  phthisis,  where  they  are  only 
occasionally  found,  they  appear  almost  constantly  in  anchy- 
lostomiasis,  always  in  anguillula,  frequently  in  ascaris  lumbri- 
coides,  oxyuris,  tenia  saginata  and  solium.  They  are  spar- 
ingly found  in  trichocephalus,  and  they  were  totally  absent  in 
the  cases  of  tenia  nana  so  rarely  observed  in  Germany  (Leich- 
tenstern).  According  to  this  author,  in  every  case  in  which 
Charcot's  crystals  are  found  in  the  feces  the  presence  of  worms 


Fig.  23. — Pennington's  Proctoscope. 


should  be  assumed  as  very  probable.     On  the  other  hand,  the 
absence  of  the  crystals  does  not  preclude  helminthiasis. 

The  fact  that  the  crystals  are  most  numerous  in  that  por- 
tion of  the  intestine  in  which  anchylostomum  is  usually  located 
{upper  ileum,  not  ditodenwn) ;  that  they  are  very  abundant  in 
the  slimy,  bile-stained  stools  induced  by  drastica  in  anguillu- 
liasis;  that  their  appearance,  even  though  seldom,  in  the  stools 


EXAMINATION 


59 


some  time  after  an  anthelmintic  course  has  been  pursued  al- 
ways points  to  incomplete  expulsion  of  worms  (retention  of 
the  particularly  tenacious  male  anchylostomum,  or  of  tape- 
worm head),  all  indicate  that  the  crystals  are  formed  at  the 
seat  of  the  parasites  (Leichtenstern). 


Fig.  24. — Bodenhamer's  Recto-colouic  Endoscope  and  Reflecting  Mirror. 

For  tJie  detection  of  intestinal  parasites,  it  is  necessary  not  only 
to  examine  for  discJiarged  zvorms,  zvorm-segments,  and  embryos, 
but  especially  for  the  ova. 

The  gfreat  sig-nificance  of  examinations  directed  to  their 


Fig.   25. — The  Martin  Proctoscope,  with  the  Obturator  in  Position. 


detection  is  shown  by  the  fact  that,  by  this  means,  it  has  re- 
peatedly been  possible  not  only  to  demonstrate  for  the  first 
time  the  presence  of  parasites,  but  by  their  expulsion  to  re- 
move severe  pathologic  conditions.  The  frequency  of  parasites 
is  shown  by  the  statistics  of  Heisig,  who  was  able  to  demon- 


60 


DISEASES  OF  THE  RECTUM  AND  ANUS 


strate  parasite-ova  in  the  stools  of  119  individuals  out  of  230 
examined  (52  per  cent.). 

In  many  instances  their  presence  is  indicated  by  no  ma- 
croscopically  demonstrable  alterations  of  the  stools.  That 
chronic  diarrhea,  which  may  cease  after  expulsion  of  tape- 
worms, is  occasionally  present,  has  already  been  mentioned. 
Recently  various  infusoria  have  been  found  in  chronic  diarrhea 
in  such  large  numbers  as  to  be  of  significance.  While,  on  the 
one  hand,  proof  of  the  etiologic  relation  of  the  infusoria  to 
the  origin  of  the  disease  could  not  be  established ;  on  the  other, 
there  was  no  doubt  that  the  infusoria  were  responsible  for  the 
perpetuation  of  the  diarrhea.     In   addition  to   the  megastoma 


Fig.  26. — The  Exaggerated  Knee-Chest,  or  Martin,  Posture. 


entericum,  cercomonas,  trichomonas,  and  peculiar  pear-shaped 
infusoria  have  been  found  in  such  conditions. 

Quincke  and  Roos,  who  first  directed  attention  to  this 
subject,  also  found  animal  parasites  in  two  cases  of  dysentery. 
In  the  first  case,  imported  from  Naples,  a  form  identic  with 
the  ameba  Loesch  was  found  which  produced  fatal  dysentery  in 
cats;  in  the  second  case,  originating  in  Kiel,  a  much  less  in- 
fectious ameba  was  observed. 

Of  the  pathogenic  bacteria  occurring  in  the  intestinal  dis- 
charges, the  bacilli  of  tuberculosis,  typhoid  fever,  and  cholera 
are  deserving  of  special  consideration.     It  should  not  be  for- 


EXAMINATION 


61 


gotten  that,  under  certain  circumstances,  the  gonococcus  also 
may  be  present.  It  may  also  be  stated  that  the  diarrheal  stools 
of  infants,  especially  the  mucous  admixtures,  very  frequently 
contain  spirilla,  the  source  of  which  is  not  quite  certain.  At 
necropsies  made  by  Escherich  upon  such  children  shortly  after 
death  these  organisms  were  found  almost  exchisively  in  the 
mucous  deposits  in  the  colon  and  especially  the  cecum. 

Discharge  of  admixed  mucus  is  of  great  clinic  signifi- 
cance. Mucus  visible  to  the  naked  eye  can  readily  and  posi- 
tively be  identified  as  such  by  its  chemic  behavior.  It  also 
occurs  in  the  form  of  yellozvish-broivn  to  dark-green  granules, 
which  were  first  pointed  out  by  Nothnagel,  If  these  are 
crushed  beneath  a  cover-glass  they  spread  out  into  a  uniform 


Fig.  27.— Patient  Prepared  and  in  Position  for  Examination  or   Operation. 


yellow  mass,  while  the  yellow  bodies  resembling  sago,  or  frog- 
spawn,  which  usually  consist  of  vegetable  remnants  and  water, 
always  remain  in  fragments.  They  are  neither  dissolved  nor 
stained  by  water,  ether,  iodin,  and  osmic  acid.  On  addition 
of  nitric  acid  they  give  a  distinct  reaction  for  bile  coloring 
matter.  An  especial  structure  is  absent.  They  always  indi- 
cate catarrh  of  the  ileum  and  upper  portion  of  the  colon;  but 
they  also  occur  in  pure  ileitis.  The  active  reaction  for  bile 
coloring  matter  with  regard  to  the  presence  of  mucus  is  of 
itself  evidence  of  the  existence  of  catarrh  of  the  ileum;  for 
the  reason  that  bile-pigment  is  normally  met  with  only  in  the 
ileum,  never  in  the  colon,  and  can  therefore  occur  in  the  feces 
only  when  there  is  very  active   peristalsis   of  the  ileum   and 


62  DISEASES  OF  THE  RECTUM  AND  ANUS 

colon.     If  along  with  the  coloring  matter  mucus  also  occurs, 
proof  of  catarrhal  ileitis  is  established. 

Cylindric  epithelial  cells  imbedded  in  mucus  are  of  frequent 
occurrence  in  different  pathologic  conditions  of  the  intestine. 
Their  form  is  usually  altered :  swollen  or  shrunken.  The  pro- 
toplasm is  granular  as  the  result  of  fatty  degeneration,  and 
contour  and  nucleus  preserved.  Unaltered  epitheUal  ceils  are 
met  with  exclusively  in  the  large  mucous  shreds.  Under  the 
term  "broken  down"  epithelia  Nothnagel  has  described  spin- 
dle-formed, slightly-glistening  bodies  which  have  been  altered 
by  desiccation.  They  occur  more  frequently  in  firm  than  in  diar- 
rheal stools. 


Fig.  28.--Esmarch's  Chloroform-inhaler. 

In  addition  to  epithelial  cells,  leucocytes  of  variable  size 
are  usually  present.  As  has  already  been  stated,  admixture 
of  pus  is  found  in  the  feces  only  in  ulcerative  processes  of  the 
intestinal  canal  or  adjacent  parts. 

CHARACTER   OF  THE   DEJECTA   IN   CERTAIN   AFFECTIONS 

1.  In  Acute  Intestinal  Catarrh  the  stools  are  more  or  less 
increased  in  number,  while  the  consistence  is  pasty  or  liquid. 
According  to  the  seat  of  the  catarrh,  certain  differences  are 
manifest : — 

(a)  If  the  ileum  only  is  affected,  there  occur  frequent,  thin 
evacuations   mixed   with   macroscopic   bile-stained   mucus   in- 


EXAMINATION 


63 


closing  numerous  cylindric  epithelial  cells;  the  above- men- 
tioned yellow  mucous  granules  (Nothnagel's)  are  also  often 
observed. 

(b)  In  catarrh  of  the  upper  portion  of  the  colon,  which  is 
usually  associated  with  catarrh  of  the  small  intestine,  the  thor- 
oughly-mixed, liquid,  soup-like  dejecta  contain  mucus  in  micro- 
scopic form  only. 

(c)  In  catarrh  of  the  rectu^n  (proctitis)  pure  gelatinoid  mucus 
is  often  expelled. 

(d)  In  catarrh  of  the  whole  large  intestine  the  liquid,  soup- 


Fig.  29. — Correct  Method  of  Digital  Examination  with  the  Patient 
in  the  Lithotomy-posture. 


like  stools  contain  macroscopic  masses  of  mucus  which  are  not 
bile-stained. 

2.  Chronic  Intestinal  Catarrh  generally  presents  the  follow- 
ing features : — 

(a)  Chronic  catarrh  of  the  ileum  does  not  occur  alone. 
Combined  with  catarrh  of  the  colon  it  induces  frequent  daily 
liquid  stools  containing  bile-stained  mucus,  yellozv  mucous 
granules,  etc. 

(b)  When  limited  to  the  colon  there  is  almost  always  a 
disposition  to  constipation  of  several  days'  duration,  which  may 


64  DISEASES  OF  THE  RECTUM  AND  ANUS 

be  interrupted  at  regular  or  quite  irregular  intervals  by  diar- 
rhea. 

(c)  In  implication  of  the  rectum,  with  or  without  disturb- 
ances of  the  lower  colon,  the  feces  are  imbedded  in  mucus. 

3.  Nervous  Diarrhea  is  of  not  infrequent  occurrence  in 
neurasthenics,  and  may  be  attended  by  six,  eight,  or  ten  alter- 
nately solid  and  liquid  stools  daily.  Now  and  then  at  certain 
meal-times  there  is  felt  a  sudden  desire  to  defecate.  The 
abundant  bilious  admixtures  which  are  often  frequent  indicate 
abnormal  peristalsis  in  the  small  and  large  intestine. 

4.  Enteritis  Membranacea. — In  this  affection  there  are  dis- 
charged at  certain  intervals,  with  or  without  stools  and  not 
infrequently  accompanied  by  violent  colicky  pains  (hence  "mu- 
cous coHc"),  membranous,  ribbon-Hke,  or  tubular  formations 
(membranous  or  tubular  enteritis).  Their  color  is  dirty  white 
and  their  length  often  considerable  (in  a  large  series  of  cases 


Fig.  30.— Rubber  Finger-stall  for  Rectal  Examination. 

Lenhartz  found  them  to  measure  between  6  and  20  centimeters 
— 2.3  to  8  inches).  The  discharges  may  be  repeated  daily  for 
weeks,  or  only  a  few  times  in  a  year.  They  are  extremely  rare 
in  children  or  neurasthenic  men,  but  much  more  frequent  in 
nervous  or  hysteric  women.  Not  infrequently  a  tendency  to  con- 
stipation is  present  at  the  same  time. 

Microscopically  there  is  observed  in  all  cases  a  delicately 
striated  basement  substance  which  may  here  and  there  present 
gHstening,  fibrin-like  fibrillation,  but  which  is  usually  clouded 
throughout  by  acetic  acid :  an  indication  that  it  consists  of 
mucus.  In  addition  there  are  often  present  very  numerous, 
greatly  altered  cylindric  epithelial  cells  and  leucocytes.  Triple 
phosphate  and  cholesterin  crystals  are  occasionally  met  with. 
Its  chemic  behavior  shows  that  it  is  composed  chiefly  of  mucus, 
in  addition  to  which  an  albuminoid  body  may  occur.  The 
coagula  are  almost  entirely  dissolved  by  caustic  potash.     Ad- 


EXAMINATION  65 

dition  of  acetic  acid  to  the  filtrate  produces  intense  clouding, 
which  almost  wholly  disappears  on  adding  an  excess  of  acetic 
acid. 

It  can  scarcely  be  doubted  that  in  this  affection,  which 
probably  attacks  nervous  subjects  exclusively,  the  process  is 
a  genuine  secretion  neurosis  in  which  the  normal  mucous  se- 
cretion is  augmented.  If  in  such  individuals  a  certain  sluggish- 
ness of  the  stools,  with  spasmodic  peristalsis  of  the  colon,  is 
also  present,  as  indeed  is  often  the  case,  the  mucus  may,  as 


Fig.  31.— Oxalate  of  Calcium,  Frequently  Found  in  Diarrhea.     (X  250.) 

Marchand  first  pointed  out,  be  molded  between  the  longitu- 
dinal folds  of  the  mucosa  of  the  colon  into  strings,  membranes, 
or  even  tubular-formed  masses. 

5.  Intestinal  Ulcers. — While  intestinal  ulcers  are  very  often 
accompanied  by  diarrhea,  this  may  occasionally  be  absent  even 
in  extensive  ulceration.  If  blood  or  pus  is  mixed  with  chronic 
diarrheal  dejecta,  this  is  strongly  suggestive  of  ulceration.  It 
should  be  especially  noted  that  ulcers  of  the  ileum,  the  sanguino- 
purulent secretion  of  which  may  not  appear  in  the  stools,  are 
generally  not  attended  by  diarrhea.    On  the  other  hand,  ulcera- 


66  DISEASES  OF  THE  EECTUM  AND  ANUS 

tion  in  the  lozver  portion  of  the  colon  and  rectum  is  ahvays  accom- 
panied by  diarrhea.  On  careful  examination  of  such  dejecta 
blood  and  pus  admixtures  are  very  rarely  absent  if  dysenteric 
ulceration  is.  present,  while  tJiese  may  be  absent  in  tubercidar  and 
catarrhal  (follicular)  idcerations.  "Smah,  grayish-white  clumps," 
consisting  of  closely-packed  pus-corpuscles,  are  only  of  occa- 
sional occurrence.  The  larger  masses  resembling  swollen  sago- 
granules,  previously  mentioned  as  indicative  of  follicular  ulcer, 
consist,  as  Nothnagel  first  noted,  almost  always  of  particles  of 
starch  or  fruit. 


/4r^ 


V 


'  r' 


Pig.  32.— Cholesterin  Crystals.     (X  100.) 

Besides  blood  and  pus,  the  "tissue-shreds,"  found  almost 
exclusively  in  the  diarrheal  stools  of  dysentery,  are  of  impor- 
tant diagnostic  significance. 

6.  Atrophy  of  the  Intestinal  Mucosa,  when  it  afifects  limited 
areas  of  the  bowel,  may  be  wholly  unattended  by  symptoms. 
In  the  not  rare  atrophy  of  the  mucosa  of  the  colon  diarrhea 
occurs,  but  the  stools  contain  neither  macroscopic  nor  micro- 
scopic evidence  of  mucus. 

7.  In  Icterus  Catarrhalis  the  stools  are  usually  clay  colored, 
firm,  and  richly  fatty.  The  fat  is  usually  present  in  the  form 
of  tufts  or  sheaves  of  needle-like  crystals,  which,  according  to 


EXAMINATION  67 

Osterlein's  researches,  probably  represent  lime  and  magnesium 
salts  of  higher  fatty  acids.  They  remain  unaltered  even  after 
twelve  hours'  treatment  with  sulphuric,  nitric,  hydrochloric, 
and  acetic  acids.  They  also  resist  the  action  of  ammonia, 
potassium,  and  sodium  hydrate;  in  short,  they  differ  very 
decidedly  from  Charcot-Leyden  crystals,  which  immediately 
disappear  on  treatment  with  these  reagents. 

8.  Degeneration  of  the  Liver  and  Hepatic  Cirrhosis.  —  In  fatty 
and  amyloid  degeneration  of  the  liver,  and  hepatitic  cirrhosis, 
quite  similar  oligo-  or  acholic  stools  also  occur  unattended  by 
icterus  or  bile-stained  urine. 

9.  Intestinal  Tuberculosis. — In  pronounced  intestinal  tuber- 
culosis tubercle  bacilli  are  very  rarely  missed  from  the  stools. 
Their  presence  in  the  dejecta  may,  therefore,  be  directly  refer- 
able to  intestinal -tuberculosis.  It  should  not  be  forgotten, 
however,  that  sputum  containing  bacilli  is  swallowed  by  pul- 
monary consumptives,  under  which  circumstances  the  bacilli 
may  appear  in  the  stools  without  the  existence  of  intestinal 
tuberculosis.  This  question  is  still  in  dispute;  in  individual 
cases  the  author  unqualifiedly  agrees  with  Lichtheim,  and 
would  diagnosticate  intestinal  tuberculosis  on  detection  of  the 
bacilli  in  the  feces. 

In  staining  it  is  better,  according  to  Lichtheim,  to  omit 
contrast  staining,  for  the  reason  that  the  innumerable  non- 
pathogenic bacteria  constantly  present  in  the  stools  (see  above) 
are  stained  and  thus  render  the  tubercle  bacilli,  which  are  usu- 
ally few  in  number,  much  more  difficult  to  find  than  when  the 
simple  "specific"  method  of  staining  the  tubercle  bacilli  is  em- 
ployed. 

Therefore  the  dry  preparations  made  from  the  mucus,  or, 
better  still,  when  present,  from  the  muco-purulent  admixtures, 
are  stained  only  in  carbol-fuchsin  or  gentian-violet-anilin-water 
solution  and  decolorized  with  hydrochloric  or  nitric  acid  and 
70  per  cent,  alcohol  (see  below).  This  must  be  so  thoroughly 
done  that  all  possibility  of  confusion  with  smegma  (pseudo- 
tubercle)  bacilli  is  excluded. 

Tubercle  Bacilli.  —  The  staining  method  of  Ziehl-Neelsen 
is  very  reliable.  The  principal  staining  fluid  in  this  method 
possesses  the  advantage  of  being  ready  for  immediate  use; 
furthermore,  its  staining  properties  are  preserved  unaltered  for 
many  months.     The  formula  for  this  fluid  is : — 


68  DISEASES  OF  THE  RECTUM  AND  ANUS 

ZieJil-Neelsen  Solution. — 

IJ  Euchsin  crystals   1  part. 

Alcohol  (98  per  cent.)   ,    10  parts. 

Acid,  carbolic,  deliquesced 5  parts. 

Distilled  water    q.  s.  ad  100  parts. 

Mix. 

Another  formula  is  : — 

IJ  Concentrated  alcoholic  solution  of  fuchsin 10  parts. 

5-per-cent.      watery      solution      of      carbolic      acid 

(crystals)    90  parts. 

Mix. 

Procedure. — Spread  the  material  or  sediment  (see  below) 
to  be  examined  in  a  thin  layer  upon  a  tiezv  slide,  and  dry  by 
the  aid  of  geittle  heat,  over  a  Bunsen  or  alcohol-flame.  When 
dry,  pass  the  preparation  a  few  times  through  the  free  flame, 
film  side  up,  to  "fix"  it.  Then  place  the  slide,  film  side  up, 
upon  an  iron  support  (or  hold  in  forceps)  and  cover  completely 
with  the  above  solution.  Heat  the  solution  on  the  slide  by 
passing-  the  flame  of  a  Bunsen  burner  or  alcohol-lamp  back 
and  forth  under  the  slide  until  the  fluid  comes  to  a  boil  once. 
The  tip  of  the  flame  may  come  in  contact  with  the  under-sur- 
face  of  the  slide,  which  hastens  boiling.  Do  not  allow  the  fluid 
to  evaporate,  but  keep  the  preparation  zuholly  covered  during  the 
heating.  If  this  precaution  is  observed  there  will  be  no  danger 
of  breaking  the  glass.  After  the  solution  has  come  to  a  boil 
wash  off  the  excess  of  stain  in  plenty  of  water,  and  place  for  a 
minute  or  two  in  5-per-cent.  watery  solution  of  sulphuric  acid, 
for  the  purpose  of  decolorizing  other  bacilli  than  those  of 
tuberculosis.  Wash  off  the  acid  solution  m  water,  and,  if  the 
preparation  is  still  quite  red,  repeat  the  washing  in  acid  until 
the  specimen,  after  washing  in  water,  assumes  a  faint-pinkish 
tinge.  Then  cover  with  the  following  contrast  staining  solu- 
tion : — 

LoefHer^s  Solution. — 

R  Concentrated  alcoholic  solution  methylene-blue.  . . .     30  parts. 

1  to  10,000  watery  solution  of  caustic  potash 100  parts. 

Mix. 

After  a  minute  or  two  wash  thoroughly  in  water,  dry,  and 
examine  in  cedar-oil  with  one-twelfth  oil-immersion  lens  with- 
out cover-glass.    The  specimen  can  be  permanently  preserved 


EXAMINATION  69 

by  blotting  off  the  cedar-oil  with  filter-paper  and  mounting 
direct  in  xylol-Canada-balsam. 

With  the  above  method  success  will  almost  always  be  at- 
tained, provided  the  specimens  prepared  contain  bacilli.  The 
latter,  however,  is  by  no  means  always  the  case,  even  in 
specimens  made  from  unquestionably  tuberculous  discharge 
or  secretion.  It  is  not  rare  for  an  examination  of  five  or  six 
preparations  to  show  but  an  occasional  bacillus ;  indeed,  in 
not  a  few  instances,  examination  of  a  comparatively  large 
number  of  specimens  may  show  no  bacilli,  even  though  the 
objective  symptoms  leave  scarcely  a  doubt  as  to  the  tuber- 
culous nature  of  the  affection.  When  the  feces  are  thin  and 
watery  they  may  be  poured  into  a  conic  glass  to  remain  for 
two  or  three  hours  to  "sediment."  In  examining  for  bacilli, 
instead  of  drawing  up  the  sediment  with  a  pipette,  it  is  prefer- 
able to  pour  oft"  the  supernatant  liquid  down  to  the  deposit 
and  to  make  a  preparation  from  the  residue  after  the  latter 
has  been  thoroughly  triturated.  The  bacilH  contained  in  this 
sediment  are  often  arranged  in  large  masses.  Sedimentation 
can  be  greatly  hastened  by  use  of  the  centrifugal  machine. 

10.  Dysentery.  —  The  stools  are  extremely  frequent  (ten, 
twenty,  and  more  in  twenty-four  hours)  and  usually  evacuated 
with  severe  pain  and  tenesmus.  While  only  a  small  quantity 
of  feces  is  discharged  with  each  dejection,  taken  collectively 
the  amount  is  often  considerable  (1000  to  1800  cubic  centi- 
meters— 33  to  60  ounces).  The  dejecta  preserve  their  fecal 
consistence  and  odor  only  in  the  earliest  stages ;  when  the 
disease  is  fully  established  they  are  composed  only  of  mucus, 
blood,  pus,  and  tissue-shreds.  According  to  the  proportion  of 
these  constituents,  we  distinguish  (just  as  with  the  sputum) 
simple  mucous,  muco-hemorrhagic,  pure  hemorrhagic,  and 
pure  purulent  stools ;  muco-purulent-hemorrhagic  mixed  forms 
are  not  infrequently  observed. 

In  the  beginning  mucus  predominates.  It  appears  as  a 
thin,  tremulous,  yellow-stained  colloid,  which  either  incloses 
particles  of  feces  still  present  in  the  early  stages  or  is  mixed 
with  them  in  large  masses.  From  the  very  beginning  the 
mucus  is  spotted  and  streaked  with  blood.  "Mucous  shreds," 
in  the  form  of  flat  coagula,  which  cover  the  stools,  are  not 
rarely  met  with. 

The  hemorrhagic  admixtures  may  in  the  beginning  be 


70  DISEASES  OF  THE  RECTUM  AND  ANUS 

simply  an  indication  of  hyperemia  of  the  mucous  membrane 
of  the  colon;  later  on  these  admixtures,  especially  those  of 
a  purely  hemorrhagic  type,  are  derived,  like  the  pus,  from  the 
existing  ulcerations.  In  more  extensive  and  deep  destruction 
of  the  intestinal  mucosa  there  appear  in  the  putrid,  stinking, 
dirty  brownish-red  or  blackish  dejecta  unquestionable  tissue- 
fragments. 

The  microscope  readily  reveals  the  presence  of  mucus  and 
pus  by  the  morphologic  and  microchemic  (acetic-acid  reaction 
of  the  mucus)  characters.  Fresh  blood  is  likewise  recognized 
by  the  presence  of  red  blood-cells,  while  old  blood  is  often 
demonstrable  only  by  means  of  chemic  and  spectroscopic  pro- 
cedures. 

The  bloody,  infiltrated,  mucous  clumps  often  contain  the 
amebas  described  as  the  cause  of  dysentery.  Quite  recently  a 
bacillus  discovered  by  Shiga,  of  Tokio,  and  confirmed  by  Flex- 
ner,  has  been  described  as  an  etiologic  factor  in  the  production 
of  dysentery. 

11.  Typhoid  Fever. — The  firm  and  formed  stools  present  in 
the  early  stage  of  typhoid  fever  usually  become,  toward  the  end 
of  the  first  week  of  the  disease,  thin  and  watery,  and  still  have 
a  distinct  brownish  color.  The  diarrhea,  which  then  begins  and 
continues  during  almost  the  whole  period  of  the  fever,  is  mani- 
fested by  five,  six,  and  more  Hght-brown,  pale-yellow,  and 
yellow-tinged  stools,  which  separate  into  two  layers  on  stand- 
ing. The  lower  one  contains  flocculent  and  lumpy  yellow 
masses,  from  which  the  upper,  more  or  less  cloudy,  brownish- 
yellow-colored,  watery  stratum  has  separated.  This  "pea-soup- 
like" stool  loses  its  Hght-grayish-yellow  color  only  toward  the 
end  of  the  disease,  during  the  gradual  decline  of  the  fever;  it 
becomes  brownish  and  gradually  more  firm  until  of  normal 
consistence. 

In  the  sediment  of  the  pea-soup-colored  stool  there  are 
found,  in  addition  to  putrefactive  bacteria  and  according  to 
the  amount  of  mucus,  a  varying  number  of  round  cells  and 
many  crystals  (triple  phosphate),  abundant  bile-pigment, 
casein-flocculi,  and,  in  stained  preparations,  now  and  then  the 
specifically  pathogenic  typhoid  bacilli. 

In  intestinal  hemorrhages,  which,  as  is  known,  occur  from 
the  end  of  the  second  to  the  fourth  week  in  from  6  to  7  per 
cent,  of  the  cases,  pure  blood  or  thick  or  slightly  coagulated, 


EXAMINATION  71 

dark  blood  may  be  discharged  not  rarely  in  large  quantity. 
If  the  hemorrhage  is  slight  or  a  large  amount  of  blood  has 
been  retained  for  some  time  in  the  intestine,  the  color  may  be 
brownish  or  even  tar  colored. 

Not  infrequently  slight  admixtures  of  blood  with  the  stool 
give  warning  of  an  impending  severe  hemorrhage.  Consequently 
these  streaks  of  blood  or  blood-stained  mucous  shreds  visible 
to  the  naked  eye  should  be  attentively  watched  for  and  their 
occurrence  given  the  most  careful  consideration. 

In  the  stools  discharged  with  severe  hemorrhage  the  red 
blood-cells  are  often  still  recognizable ;  in  the  blood  which  has 
been  much  altered  in  color,  even  the  "ghosts"  of  the  red  blood- 
corpuscles  are  absent.  Under  such  circumstances  recourse 
must  be  had  to  the  demonstration  of  the  blood  coloring  matter 
by  TeicJimann's  hemin  test,  or  by  means  of  the  spectroscope,  but 
with  the  latter  it  must  be  remembered  that  the  oxyhemoglobin 
may  have  been  transformed  into  methemoglobin. 

12.  Cholera. — The  characteristic  "rice-water"  or  "oatmeal- 
soup-like"  stools  are  usually  very  frequent  and  profuse.  Owing 
to  the  absence  of  bile-pigment,  they  are  liquid,  grayish-white, 
mixed  with  Hght-colored  flocculi,  resembling  cooked  rice,  and 
devoid  of  fecal  odor. 

Microscopic  examination  of  a  simple  unstained  "crush" 
preparation  made  from  one  of  the  light-colored  mucous  floc- 
culi shows  that  these  are  composed  of  closely-arranged,  swollen 
cylindric  epithelial  cells  and  mucus,  among  which  are  numer- 
ous bacteria  of  all  varieties. 

Consequently  it  is  very  seldom  that  the  specific  infectious 
agent  can  be  recognized  in  such  a  specimen  that  has  been  dried 
and  stained.  For  this  purpose  cultivation  is  necessary.  Koch 
and  numerous  other  investigators  observed  on  former  occa- 
sions and  also  in  the  severe  epidemic  at  Hamburg,  in  1892,  a 
number  of  cases  in  which  the  comma  bacilli  were  present  in 
the  stained  preparations  in  almost  pure  culture  and  noted  espe- 
cially the  characteristic  grouping  of  the  bacilli  in  the  mucous 
flocculi.  In  some  of  such  cases  the  diagnosis  can  be  made  with 
great  probability  without  cultivation,  because  the  comma  ba- 
cilli are  distinguished  from  other  comma  forms  by  their  shorter, 
thicker,  and  more  curved  form,  and  their  characteristic  clumped 
arrangement. 


72  DISEASES  OF  THE  RECTUM  AND  ANUS 

13.  In  Syphilis  of  the  Rectum  mucus  and  blood  are  not  infre- 
quently discharged  with  the  feces. 

14.  In  Cancer  of  the  Rectum  frequent,  non-feculent  discharge 
of  blood  and  mucus  accompanied  by  tenesmus  is  particularly 
characteristic.  When  the  seat  of  cancer  is  higher  up,  putrid, 
stinking  dejecta,  very  rarely  containing  cancer-fragments,  may 
support  a  diagnosis.  On  the  other  hand,  tape-like  or  sheep- 
manure-Hke  stools  are  of  no  differential  diagnostic  significance. 

15.  Intussusceptions  of  the  intestine  lead  to  bloody-mucoid 
dejecta,  more  rarely  to  expulsion  of  necrotic  portions  of  intes- 
tine. Embolism  of  the  mesenteric  artery,  severe  congestion  of 
the  portal  vein,  and  scorbutus  also  give  rise  to  bloody  stools. 


CHAPTER  V 

CONGENITAL  MALFORMATIONS 

Congenital  malformations  of  the  rectum  and  anus  are 
encountered  with  a  regularity  corresponding  to  similar  de- 
fects in  other  parts  of  the  body.  Boys  are  more  frequently 
afBicted  than  girls.  These  deformities  are  the  result  of  ar- 
rested or  imperfect  development  during  fetal  life.  Readers 
who  desire  information  as  to  the  exact  manner  in  which  this 
occurs  are  referred  to  standard  works  on  embryology. 

To  an  American  surgeon — Dr.  Wilham  Bodenhamer,  of 
New  Rochelle,  N.  Y. — belongs  the  honor  of  writing  the  first 
exhaustive  and  generally  accepted  treatise  on  congenital  mal- 
formations of  the  rectum  and  anus.  This  work,  published  in 
1860,  contained  a  collection  of  287  cases,  including  every  de- 
formity known  to  occur  in  these  regions.  Prior  to  this  time 
the  literature  consisted  principally  of  magazine  articles.  The 
most  prominent  contributors  were  Bell,  Copeland,  and  Hutch- 
inson, of  England;  MM.  Amusat  and  Roux  de  Brignotes,  of 
France;  von  Amon  and  Friedberg,  of  Germany;  and  Bushe, 
Barton,  and  Gay,  of  the  United  States.  It  must  not  be  for- 
gotten, however,  that  these  deformities  were  described  with 
accuracy  by  the  ancients.  Bodenhamer  states  that  they  were 
noticed  by  the  Greek,  Roman,  and. Arabic  physicians. 

There  occurs,  in  round  numbers,  about  1  malformation 
of  the  rectum  or  the  anus  in  every  10,000  births.  Statistics, 
however,  are  unreliable,  and  do  not  represent  the  number  of 
these  cases  met  with,  for  the  reason  that  they  are  not  of  suffi- 
cient interest  to  the  average  physician  to  urge  him  to  record 
them.  The  author  knows  of  at  least  10  children  who  have  been 
operated  on  for  congenital  occlusion,  and  not  a  single  case  has 
been  recorded. 

CLASSIFICATION 

Authors  differ  in  their  classification  of  these  deformities. 
The  most  complete  classification  is  that  of  Papendorf,  which 
has  been  adopted,  with  slight  modifications,  by  Bodenhamer, 

(73) 


74 


DISEASES  OF  THE  RECTUM  AND  ANUS 


Esmarch,  Molliere,  Mathews,  Ball,  and  others.  The  author 
prefers  the  arrangement  of  this  subject  as  made  by  Cooper 
and  Edwards,^  which  includes  the  following  six  varieties  under 
two  general  headings : — 

1.  Imperforate  Anus. — 1.  Congenital  narrowing  of  the  anus, 
without  complete  occlusion,  but  sometimes  accompanied  by  a 
fecal  fistula. 

2.  Closure  of  the  anus  by  membranous  tissue. 

3.  Entire  absence  of  the  anus,  the  rectum  ending  in  a 
blind  pouch  at  a  varying  distance  from  the  perineum. 


Fig.  33.— Narrowing  of  the  Anus  Witiiout  Complete  Occlusion. 


4.  Imperforate  anus,  with  fecal  fistula  opening  (a)  into 
the  vagina;  (b)  into  the  bladder  or  urethra;  (c)  upon  the 
surface  of  the  body. 

II.  Imperforate  Rectum,  with   Anus  in  Normal  Position 5. 

Membranous  obstruction  of  the  rectum. 

6.  Extensive  obliteration  or  total  absence  of  the  rectum. 

1.  Congenital  Narrowing  of  the  Anus,  Without  Complete 
Occlusion. — In  this  variety  (Fig.  33)  the  rectum  or  anus  is 
unusually  tight,  and  the  alvine  discharges  are  evacuated  with 
great  difficulty;  in  exceptional  cases  the  constriction  is  so  close 


1  "Diseases  of  the  Rectum  and  Anus,"  Cooper  and  Edwards,  second  edition,  page 
44,  1892. 


CONGENITAL  MALFORMATIONS 


75 


that  the  meconium  is  retained  or  dribbles  out  slowly.  The 
defect  may  be  due  to  extension  of  the  skin  or  musculature  of 
the  anal  outlet  across  the  anal  margin. 

2.  Closure  of  the  Anus  by  Membranous  Tissue. — The  author 
has  found  this  condition  easy  to  diagnosticate  and  cure.  Here 
the  anus  may  be  well  formed  and  the  bowel  continuous.  The 
obstruction  is  caused  by  a  membranous  partition  (Fig.  34) 
which  extends  from  the  side  of  the  bowel,  immediately  above 
the  anal  aperture. 

3.  Entire  Absence  of  the  Anus,  the  Rectum  Ending  in  a 
Blind  Pouch  at  a  Varying  Distance  Above  the  Perineum. — In  this 


Fig.  34. — Closure  of  the  Anus  by  Membranous  Tissue. 


class  of  congenital  defects  simple  and  complex  cases  are  met 
with.  Nothing  except  a  dimple  marks  the  natural  location 
of  the  anus,  the  rectum  terminating  in  a  blind  pouch  (Fig. 
35)  at  a  greater  or  less  distance  above  the  normal  site  of  the 
anus.  The  space  intervening  between  this  point  and  the  skin 
is  filled  with  connective  tissue. 

4.  Imperforate  Anus,  with  Fecal  Fistula.  —  In  this  variety 
the  anus  is  absent.  The  intestinal  contents  escape  by  means 
of  a  fistulous  opening  into  the  urethra,  vagina  (Fig.  36), 
bladder,  or  upon  the  surface  of  the  body.  The  vagina  is  the 
usual  site,  and  the  opening  is  sufficiently  large  to  permit  dis- 


76  DISEASES  OF  THE  RECTUM  AND  ANUS 

charge  of  meconium  and  in  exceptional  cases  the  free  evacua- 
tion of  sohd  feces.  The  author  a  few  years  ago  successfuhy 
operated  on  a  woman  suffering  from  an  abnormahty  of  this 
type  and  estabHshed  the  anus  at  its  normal  site.  In  this  case 
ah  fecal  matter  was  discharged  through  the  vagina  up  to  the 
time  of  operation. 

When  the  bowel  communicates  with  the  urethra  (Fig. 
37)  or  bladder  (Fig.  38)  the  danger  is  greatly  increased, 
though  cases  of  both  types  have  been  recorded  where  children 
lived  so  afflicted  for  many  years.  The  latter  deformity  is  more 
frequently  met  with. 


Fig.  35. — Imperforate  Anus,  the  Rectum  Terminating  Par 
Above  in  a  Blind  Pouch. 

Mr.  Page,  of  London,  treated  a  gentleman,  54  years  old, 
who  had  throughout  his  life  discharged  both  feces  and  urine 
per  iirethram.  He  declined  all  relief  other  than  enlargement 
of  the  fistulous  opening.  The  urethra  was  slit  up  and  the 
mucous  membrane  attached  to  the  skin.  Four  months  later 
he  was  quite  comfortable. 

AVhen  intestinal  contents  finds  its  way  into  the  bladder 
much  suffering  follows,  and  in  most  instances  death  occurs 
early  as  a  result  of  obstruction.  When  the  fistulae  open  upon 
the  surface  of  the  body  the  outlets  may  be  single  or  multiple. 
The  opening  at  times  may  be  located  in  the  scrotum,  the  penis 


CONGENITAL  MALFORMATIONS 


77 


(Fig.  39),  or  tlie  gluteal,  lumbar,  or  sacral  regions.  The 
danger  and  suffering  depend  upon  both  the  size  and  location 
of  the  openings. 

5.  Membranous  Obstruction  of  the  Rectum  resembles  the  sec- 
ond variety  in  so  far  as  the  occlusion  is  caused  by  a  membra- 
nous partition.  Here,  however,  the  obstruction  is  situated  in 
the  rectum  a  considerable  distance  above  the  anus  (Fig.  40), 
which  is  perfectly  natural  in  appearance  and  location. 

6.  Extensive  Obliteration  or  Total  Absence  of  the  Rectum. — 
Malformations   of  this   class   are  frequently   overlooked   until 


Fig.  36.— Imperforate  Anus,  the  Rectum  Opening  into  the  Vagina. 


their  presence  is  revealed  by  a  necropsy.  This  is  because  an 
ocular  examination  of  the  terminal  rectum  shows  it  to  be 
normal.  Sometimes  the  rectum  ends  in  a  blind  sac,  the  lower 
portion  of  which  may  be  only  a  short  distance  or  several  inches 
above  the  anus.  In  rare  instances  the  rectum  and  the  sigmoid 
are  entirely  obliterated. 

Examples  of  the  various  types  of  congenital  malforma- 
tions of  the  rectum  and  anus  have  been  purposely  omitted. 
Readers  who  desire  to  study  these  manifestations  in  detail  are 
referred  to  Bodenhamer's  work. 


78 


DISEASES  OF  THE  KECTUM  AND  ANUS 


SYMPTOMS 

Symptoms  induced  by  congenital  occlusion  of  the  rectum 
or  the  anus  may  appear  gradually  or  become  urgent  within  a 
few  hours  after  birth.  Usually,  children  so  afflicted  live  only 
a  few  days ;  in  exceptional  cases,  however,  they  have  remained 
in  comparative  comfort  for  several  weeks.  Shipman^  has  re- 
corded the  case  of  a  child  which  lived  more  than  three  months 
without  discharging  anything  from  the  bowel.  The  majority 
of  these  infants  develop  violent  symptoms  and  die  within  forty- 


Fig.  37. — Imperforate  Anus,  the  Rectum  Terminating  in  the  Urethra. 


eight  hours  unless  relieved  by  surgical  intervention.  The  first 
manifestation  observed  is  the  absence  of  the  stool,  and  conse- 
quently the  retention  of  the  meconium.  Then  follows  the 
usual  symptoms  of  intestinal  obstruction :  the  little  patient 
becomes  restless,  feverish,  cries  most  of  the  time,  frequently 
strains  to  relieve  the  bowel,  the  abdomen  grows  tense,  the 
pulse  is  weak  and  thread-like,  the  temperature  irregular,  res- 
piration difhcult,  the  face  expresses  suffering;  then  occurs 
vomiting,  first  of  the  gastric  and  later  of  the  intestinal  con- 
tents, including  meconium ;   the  extremities  become  cold,  and 

^  Boston  Medical  and  Surgical  Journal,  October,  1838. 


CONGENITAL  MALFORMATIONS 


79 


death  finally  ensues  from  exhaustion  and  lack  of  nourishment 
or  from  rupture  of  the  intestine  and  collapse. 

The  symptoms  differ  in  the  various  types  of  congenital 
occlusion.  In  the  first  variety,  where  narrowing  of  the  anus 
only  is  present,  constipation  and  diarrhea  are  noticeable,  or 
the  meconium  may  be  slowly  discharged.  Where  a  fistula 
opens  into  the  urethra  or  bladder  the  urine  has  a  fecal  odor. 
The  irritation  caused  by  the  feces  induces  urethritis  or  cystitis, 
respectively.  When  there  is  a  communication  with  the  vagina 
the  opening  is  usually  large,  and  the  feces  are  expelled  with 


Fig.  38. — Imperforate  Anus,  the  Rectum  Terminating  In  the  Bladder. 

little  pain  beyond  that  depending  upon  excoriation  of  the  gen- 
itals. 

DIAGNOSIS 

When  undue  contraction  of  the  anus  or  the  rectum  exists 
in  the  newly-born  a  diagnosis  is  usually  easy.  The  contraction 
when  high  can  be  located  with  the  finger  or  a  probe,  and  when 
near  the  anus  can  be  easily  seen,  especially  if  it  is  due  to  a 
fold  of  skin  stretching  partially  over  the  anal  aperture. 

When  the  occlusion  is  complete  and  induced  by  a  mem- 
brane, a  correct  diagnosis  can  readily  be  reached  from  the 
bulging  caused  by  pressure  of  retained  meconium  upon  the 
bowel  when  the  child  cries  or  cousfhs.     In  those  cases  where 


80 


DISEASES  OF  THE  EECTUM  AND  ANUS 


the  anus  is  absent  and  the  rectum  ends  in  a  sac,  much  in- 
genuity is  required  to  determine  the  exact  condition,  because 
there  are  no  external  manifestations  to  serve  as  a  guide.  Much 
information  is  to  be  obtained  by  pressing  the  abdominal  con- 
tents downward  with  one  hand  while  the  perineum  is  palpated 
with  the  other  to  ascertain  whether  the  distended  rectum  can 
be  reached.  When  the  perineum  and  the  end  of  the  rectal 
pouch  are  more  than  one  inch  (2.54  centimeters)  apart,  no  im- 
pulse can  be  felt;  when  the  distance  is  less,  it  can  usually  be 
detected. 

Where  obstruction  is  dependent  upon  an  imperforate  rec- 


Fig.  39.— Imperforate  Anus,  the  Rectum  Opening  on  the  Surface  by  Means  of 
a  Fistulous  Sinus  through  the  Penis. 


turn  due  to  occlusion  of  the  bowel  by  a  membranous  partition 
or  a  bhnd  end,  the  real  trouble  is  frequently  unsuspected  until 
the  patient  is  beyond  help,  because  the  anus  is  natural  in  ap- 
pearance. The  little  finger  introduced  into  the  rectum  will 
at  once  detect  the  trouble,  except  in  those  instances  in  which 
the  deformity  is  situated  very  high  or  the  rectum  is  entirely 
obliterated.  In  cases  where  the  diagnosis  cannot  be  made  by 
percussion  and  palpation,  celiotomy  should  be  performed 
without  delay.  When  congenital  malformation  is  complicated 
by  fistula,  the  meconium,  gas,  and  feces  escape  either  with  the 
urine,  through  the  vagina,  or  upon  the  surface,  through  an 
external  opening. 


CONGENITAL  MALFORMATIONS 


81 


PROGNOSIS 

From  what  has  ah'eady  been  said,  it  is  plain  that  the 
prognosis  in  congenital  malformation  of  the  rectum  or  the 
anus  is  good  in  some  cases  and  unfavorable  in  others.  Chil- 
dren suffering  from  narrowing  of  the  anus  or  the  rectum  are 
quickly  relieved  by  divulsion,  and,  when  necessary,  incision. 
Imperforate  anus  due  to  a  membrane  extending  across  the 
anal  aperture  is  easily  remedied,  and  seldom  causes  death. 
The  mortality  is  greatly  increased,  however,  in  cases  where 
the  inferior  portion  of  the  rectum  is  absent  for  one  or  more 


Fig.  40. — Imperforate  Rectum.    The  Anus  Natural,  but  the  Rectum  is  Obstructed 
Some  Distance  Above  it  by  a  Membranous  Partition. 


inches.  Here  extensive  cutting  is  necessary,  and,  as  the  newly- 
born  child  has  little  vitality,  it  often  dies  from  shock.  When 
the  rectum  can  be  opened  and  united  to  the  skin  the  prognosis 
is  fair,  but  when  this  cannot  be  accomplished  the  discharge 
escapes  through  an  artificial  channel  unprotected  by  mucous 
membrane  and  unsupported  by  muscular  tissue.  As  a  result 
of  this  unnatural  condition,  annoying  and  dangerous  compli- 
cations are  to  be  expected  immediately  after  the  operation  and 
also  later  in  life.  The  most  distressing  sequel  is  the  formation 
of  tight  cicatricial  strictures.  It  was  these  dangers  which  led 
the  older  surgeons  to  choose  opening  the  bowel  in  the  in- 


83 


DISEASES  OF  THE  RECTUM  AND  ANUS 


guinal  region  rather  than  from  below.  Fistulous  communica- 
tions between  the  bowel  and  other  organs  add  another  element 
of  danger  to  the  successful  treatment  of  congenital  deformities 
of  the  rectum  and  the  anus. 

The  mortality  following  operations  for  the  relief  of  con- 
genital malformations  of  the  rectum  and  the  anus  has  been 
considerably  reduced  by  the  modern  methods  of  asepsis. 
Three  tables  of  cases  are  given,  in  order  that  the  reader  may 
study  the  frequency  of  the  different  varieties  of  congenital  mal- 
formation of  the  rectum  and  anus,  the  treatment  adopted  for 
their  relief,  and  the  results  obtained. 

Table  I.    Synopsis  of  Eight  Cases  of  Congenital  Malformation  of 
THE  Eectum  and  Anus  Tkeated  by  the  Authob. 


No. 

Sex. 

1 

Male 

2 

Female 

3 

Male 

4 

Male 

5 

Female 

6 

Male 

7 

Female 

8 

Male 

Age. 


Variety  of  Deformity. 


Treatment. 


Result. 


36  hrs.       Anus  occluded  by  mem- 
branous tissue. 


22  yrs. 


2  days 


24  hrs. 


5  days 


2  weeks 


3  days 


4  days 


Natural  anus.  Imperfo- 
rate rectum  opening  into 
vagina,  through  which  all 
feces  had  been  voided  dur- 
ing life. 


Rectum  ended  in  pouch 
3  inches  (3.82  centimeters) 
above  the  anus.  Fistulous 
communication  between  it 
and  the  bladder. 

Anal  aperture  partially 
covered  by  skin. 

Imperforate  rectum  ;  anus 
natural. 


Congenital  narrowing  of 
both  rectum  and  anus. 


Rectum  ended  in  blind 
pouch  1  inch  (2  54  centi- 
meters) above  the  anus. 


Imperforate  anus  caused 
by  fibrous  partition  extend- 
ing entirely  across  the 
lumen  of  the  bowel  about 
one  inch  (2.o4  centimeters) 
above  the  anus. 


Membrane  incised  and 
anus  dilated  with  finger. 

Rectal  end  of  fistula  freed 
from  vaginal  wall  by  an 
elliptic  incision.  The  end 
of  the  rectum  was  then 
reached  by  another  deep 
incision,  opened,  brought 
down,  and  sutured  to  the 
normal  anal  site. 

All  efforts  to  reach  the 
rectum  and  bring  it  down 
were  fruitless;  left  iliac 
colostomy  was  performed. 

Integument  cut  away  and 
anus  divulsed. 

Real  condition  was  not 
suspected  by  the  family 
physician  until  the  child 
was  moribund,  when  I  was 
called  in  ;  operation  refused. 

Divulsion  with  bougies 
gave  only  temporary  relief; 
iliac  colostomy  eventually 
made. 

Incision  carried  back- 
ward and  upward  until  the 
rectum  was  located,  opened, 
and  united  to  skin  at  anal 
site. 

Membrane  incised  at  sev- 
eral points ;  trimmed  off. 
Rectum  divulsed  immedi- 
ately and  at  intervals  of 
one  week  for  six  months 
thereafter. 


Recovery. 


Recovery ;  partial 
incontinence. 


Death  five  hours 
later. 


Recovery. 


Death    in    few 
hours. 


Recovery;  still 
living. 


Recovery ;  strict- 
ure. 


Recovery;  slight 
constriction  at  site 
of  original  trouble. 


The  following  table  is  taken  from  Cripps,  and  shows  the 
mortality  in  100  cases  operated  on  by  him : — 


CONGENITAL  MALFORMATIONS 


83 


Table  II.    Congenital  Malformations  (Ceipps) 

1.  Colon   opened,  in  the  groin 16  11 

2.  Colon  opened  in  the  loin 3  2 

3.  Puncture    17  14 

4.  Coccyx  resected   8  5 

5.  Perineal  incision   or  dissection 39  14 

6.  Communication  between  rectum  and  vagina.  . .     14  1 

7.  Miscellaneous    3  3 

Total    100  50 

Table  III.    Congenital  Malfokmations  (Bodenhamer) 


u. 
O    . 

|- 
z 

z 

a. 
0 

Result. 

0:  111 
UJ  H 

tn  < 
s.  ^ 

|s 

Result. 

2s3q 

Species. 

U  q: 

a 

tq 

Q 

OS 
a" 

Q 
u 

Q 

Total. 

First  species 

Second   "      

Third      "      

Fourth     "      

Fifth        "      

Sixth       "      

Seventh  "      

Eighth     "      

Ninth       "      

12 
16 
53 
45 

25 
85 
17 
28 
6 

10 
14 
49 
36 
14 
27 

■5 

1 

8 
8 
23 
20 
13 
15 

2 

6 

26 

16 

1 

12 

"5 

1 

1 
1 

8 

1 

22 

'6 
1 

"i 
11 

1 

2 
1 
8 

ii 

'6 

1 

1 

'3 

1 

10 
36 
17 
17 

4 

12 
16 
53 
45 
25 
85 
17 
28 
6 

287 

156 

87 

69 

42 

12 

30 

89 

287 

This  table  gives  the  whole  number  of  cases  collected  by 
Bodenhamer;  also  the  number  of  each  species,  the  number 
treated  or  operated  on  and  the  result,  the  number  not  operated 
on  and  the  result,  and  the  number  of  those  cases  in  which 
neither  the  treatment  nor  the  result  is  reported.  It  will  be 
seen  that  it  comprises  by  far  the  largest  number  of  cases  ever 
before  collected  by  a  single  individual. 


TREATMENT 

First  Variety. — Congenital  atresia  of  the  rectum  or  the 
anus  requires  the  same  treatment  as  stricture  in  other  parts 
of  the  body.  In  the  majority  of  cases  a  more  serious  opera- 
tion than  divulsion  of  the  constriction  with  the  finger  is  uncalled 
for.  In  exceptional  cases  dilatation  should  be  preceded  by 
an  incision  to  make  room  for  the  finger.     The  rectum  should 


84  DISEASES  OF  THE  RECTUM  AND  ANUS 

be  Stretched  with  bougies  from  time  to  time  to  prevent  con- 
traction. 

Second  Variety. — Imperforate  anus  due  to  a  membrane  is 
easily  corrected  by  seizing  the  membrane  in  the  center  with 
a  strong  pair  of  forceps  and  then  carefully  trimming  it  off 
down  to  the  junction  of  the  external  sphincter.  The  muscle 
will  be  recognized  as  the  raised  rim  around  the  dimple  where 
the  anus  should  be.  A  piece  of  sterile  gauze  is  then  placed 
over  the  raw  surface.  The  after-treatment  consists  in  dilating 
the  anus  when  there  is  a  tendency  to  stricture  and  keeping  the 
stools  liquid. 

Third  Variety. — When  the  anus  is  absent  and  the  rectum 
terminates  in  a  ciil-de-sac  at  a  varying  distance  above  the  peri- 
neum, extensive  dissections  and  considerable  ingenuity  are 
required  to  correct  the  deformity. 

Proctoplasty.  —  It  is  desirable  to  operate  just  as  soon  as 
the  diagnosis  has  been  made.  The  best  results  are  attained 
where  the  incision  is  made  over  the  anus  and  back  to  the  coc- 
cyx. Removal  of  the  latter  is  desirable  when  more  room  is 
needed.  The  wound  is  then  enlarged  and  deepened  with  blunt 
scissors  until  the  lower  end  of  the  rectal  pouch  is  reached. 
The  rectum  is  next  opened,  and,  after  the  meconium  and  in- 
testinal debris  have  been  allowed  to  escape,  the  lower  end  of 
the  bowel  is  pulled  down  to  the  anal  site  and  anchored  to  the 
skin  (Amussat)  by  interrupted  catgut  sutures.  When  this  is 
not  feasible,  free  exit  to  the  feces  must  be  secured  by  keeping 
the  space  between  the  lower  end  of  the  cul-de-sac  and  the  anus 
open  until  the  mucous  membrane  approaches  the  anus  or  a 
permanent  fistula  is  estabHshed.  When  the  rectum  cannot  be 
reached  from  below,  a  colostomy  should  be  made  immediately. 
The  old  operation  of  draining  the  rectum  by  means  of  an  aspi- 
rator is  a  dangerous  procedure,  because  it  is  impossible  to  tell 
when  the  instrument  enters  the  peritoneal  cavity.  Further- 
more, this  operation  is  unsatisfactory,  for  the  reason  that  per- 
manent benefit  is  not  secured. 

Fourth  Variety. — In  this  form  of  imperforate  anus  the 
condition  is  similar  to  that  just  described,  except  that  there  is 
also  present  a  fistulous  communication  between  the  rectum, 
vagina,  urethra,  bladder,  or  the  surface  of  the  body. 

Fecal  Fistula  Terminating  in  the  Vagina  is  less  difficult  to 
correct  than  some  of  the  other  varieties.     A  grooved  director 


CONGENITAL  MALFORMATIONS  85 

is  passed  through  the  recto-vaginal  opening  to  a  point  in  the 
perineum,  where  it  is  intended  to  make  tlie  anus,  and  the  tis- 
sues thereon  divided.  The  rectum  sliould  then  be  freed,  low- 
ered, and  sutured  to  the  anal  site.  Some  surgeons  prefer  to 
leave  the  entire  wound  open  and  to  heal  by  granulation.  In 
a  woman  22  years  old,  treated  by  the  author,  the  sphincter  ani 
was  implanted  in  the  vaginal  wall.  In  operating  on  this  case 
the  rectal  insertion  in  the  vagina  was  included  in  two  elliptic 
incisions,  and  the  dissections  extended  until  the  bowel  was 
freed  from  its  attachments  and  restored  to  its  natural  location. 
No  incontinence  followed  this  procedure  (Rizzoli's  operation), 
and  the  woman  made  a  good  recovery.  In  some  cases,  when 
the  vaginal  outlet  is  sufficiently  large  to  permit  the  fecal  dis- 
charges to  pass  without  pain,  it  is  best  not  to  operate. 

Fecal  Fistula  Terminating  in  the  UretJira  and  Bladder. — It 
is  extremely  difficult  to  rectify  a  fecal  fistula  which  terminates 
in  the  urethra,  and  still  more  arduous  to  correct  one  ending 
in  the  bladder.  When  feasible,  the  rectum  should  be  opened 
and  an  artificial  anus  established  in  the  perineum  according  to 
the  previously  described  plan  of  Amussat.  In  cases  where  the 
rectum  opens  into  the  urethra  or  bladder,  operative  procedures 
are  indicated  as  soon  as  the  conditions  have  been  recognized. 

When  the  opening  is  in  the  urethra  and  death  is  likely 
to  ensue  in  a  short  time  because  of  obstruction,  it  should  be 
enlarged  by  incising  the  urethra.  This  will  give  temporary 
and  sometimes  permanent  relief  by  permitting  evacuation  of 
intestinal  contents.  If  the  surgeon  has  been  successful  in  re- 
storing the  rectum  to  its  natural  site,  the  edges  of  the  fistulous 
opening  may  later  on  be  freshened  and  sutured  together  by  a 
plastic  operation.  In  extreme  cases,  when  death  is  imminent 
and  there  is  no  opportunity  to  relieve  the  obstruction  from 
below,  colostomy  should  be  performed  immediately. 

Recto-vesical  Fistula  in  the  newly-born  is  a  much  more  seri- 
ous condition  than  the  variety  just  described.  The  mortality 
following  operations  in  this  class  of  congenital  malformations 
is  quite  high :    rather  more  than  50  per  cent. 

In  a  child  only  two  or  three,  days  old  it  is  useless  to 
attempt  to  close  the  fistulous  communications,  because  exten- 
sive cutting  is  necessary  and  death  would  ensue  from  shock 
or  peritonitis.  It  is  also  inadvisable  in  most  cases  to  restore 
the  rectum  to  its  usual  location,  for  the  reason  that  all  or  a 


86  DISEASES  OF  THE  KECTUM  AND  ANUS 

portion  of  the  feces  and  gases  would  continue  to  pass  into  the 
bladder  and  eventually  cause  obstruction  or  death. 

The  best  immediate  and  permanent  results  in  this  class 
of  cases  have  followed  the  estabhshment  of  an  artificial  anus 
in  the  iliac  region,  or  in  the  transverse  or  descending  colon 
when  the  rectum  and  sigmoid  were  obliterated.  The  manner 
of  performing  this  operation  has  been  described  elsewhere. 

Fecal  Fistula  Opening  upon  the  Surface  of  the  Body  may  select 
various  locaHties  for  its  termination,  such  as  the  scrotum,  penis, 
or  gluteal,  sacral,  or  lumbar  regions.  There  may  be  one  or 
more  openings.  This  being  true,  set  rules  cannot  be  followed 
in  the  treatment  of  this  condition.  When  the  opening  is  small 
and  obstruction  has  taken  place,  the  fistulous  channel  may  be 
enlarged  with  a  probe-pointed  bistoury  toward  the  median  line 
and  up  to  the  rectal  cul-de-sac.  Then,  if  the  edges  of  the  incised 
and  detached  rectum  can  be  united  to  the  skin,  a  good  result 
may  be  expected.  In  many  instances  this  is  impossible,  and  all 
that  can  then  be  done  is  to  enlarge  the  sinus  sufficiently  to 
relieve  and  prevent  obstruction.  When  carefully  handled, 
many  of  these  little  patients  enjoy  a  fairly  comfortable  exist- 
ence and  may  reach  mature  years.  In  unfavorable  cases  it  is 
necessary  to  do  an  abdominal  operation  and  allow  the  fecal 
matter  to  discharge  through  an  opening  in  the  groin. 

Fifth  Variety. — -In  this  form  of  congenital  defect  the  anus 
looks  perfectly  natural,  yet  the  rectum  is  imperforate  (ob- 
structed), caused  by  one  or  more  membranous  partitions. 
Because  of  the  natural  appearance  of  the  parts,  the  real  con- 
dition is  not  suspected  at  first,  and  the  surgeon  is  not  called 
until  dangerous  manifestations  of  occlusion  are  present.  The 
author  treated  one  case  of  this  nature  where  the  obstructing 
membrane  was  located  one  inch  (2.54:  centimeters)  above  the 
anus. 

Under  general  anesthesia  a  probe-pointed  bistoury  was 
inserted  into  the  bowel  and  guided  upward  until  the  obstruc- 
tion was  detected;  it  was  then  forced  through  and  the  mem- 
brane completely  incised.  The  finger  was  then  passed  into 
the  opening  and  the  bowel  at  this  point  thoroughly  stretched; 
irrigation  of  the  rectum  completed  the  operation.  The  after- 
treatment  consisted  in  divulsing  the  bowel  daily  for  two  weeks 
with  the  smallest  size  Wales  soft-rubber  bougie.     Except  a 


CONGENITAL  MALFORMATIONS  87 

slight  tendency  to  constriction,  recovery  was  prompt  and  per- 
fect. 

An  operation  similar  to  the  one  performed  in  the  case  just 
reported  seems  to  meet  all  requirements,  unless  the  child  is  in 
imminent  danger  of  obstruction  caused  by  enormous  disten-' 
sion.  When  such  a  state  of  affairs  exists,  time  is  most  impor- 
tant, and  the  distended  bowel  should  be  relieved  immediately 
by  an  opening  made  through  the  obstructing  diaphragm  with 
either  the  knife,  trocar,  or  finger.  When  symptoms  of  ob- 
struction have  disappeared  and  there  are  indications  for  it,  a 
more  satisfactory  operation  can  be  made  at  a  later  date. 

Sixth  Variety. — This  species  of  congenital  deformity  is 
perhaps  the  most  serious  met  with  in  the  ano-rectal  region. 
The  anus  is  natural  in  location  and  appearance,  while  the  rec- 
tum is  partially  or  totally  obliterated.  When  the  latter  ends 
in  a  blind  pouch  at  a  distance  which  can  be  safely  reached  by 
incisions  from  below,  it  should  be  detached,  opened,  brought 
down,  and  united  to  the  skin  in  the  anal  region.  When  this 
operation  is  inadmissible,  colostomy  is  the  only  resource  at 
our  command  which  offers  both  temporary  and  lasting  relief. 
When  occlusion  is  complete  and  there  is  considerable  disten- 
sion, this  operation  is  imperative,  and  should  be  made  at  the 
earliest  opportunity. 

Inguinal  (Iliac)  Colostomy  (Colotomy) — Littre's  Operation. — ■ 
The  idea  of  establishing  an  artificial  anus  for  the  relief 
of  infants  suffering  from  a  congenital  deformity  of  the  rectum 
and  of  the  anus  was  first  suggested  and  outlined  by  M. 
Littre  in  1710.  Considerably  more  than  half  a  century  elapsed 
before  this  operation  was  performed  on  the  living.  In  the 
year  1776  M.  Pilore  made  an  artificial  anus  in  the  cecum  for 
the  rehef  of  an  obstruction  caused  by  a  malignant  growth. 
Bodenhamer,  however,  maintains  that  M.  Dubois,  1783,  was 
the  first  surgeon  to  perform  this  operation  for  a  congenital 
defect  in  the  ano-rectal  region. 

Lumbar  Colostomy — Callisen-Amussat  Operation.  —  In  1770 
Callisen  described  an  operation  whereby  the  colon  could  be 
reached  and  opened  without  injury  to  the  peritoneum  by 
means  of  an  incision  in  the  lumbar  region.  This  procedure 
remained  in  disfavor  until  it  was  slightly  modified  and  cham- 
pioned by  Amussat  in  a  series  of  papers  during  the  years  from 
1835  to  1843.    Since  the  pubhcation  of  these  articles  the  opera- 


88  DISEASES  OF  THE  RECTUM  AND  ANUS 

tion  of  lumbar  colostomy  has  been  designated  "Amussat's  op- 
eration." The  author  would  suggest  that  the  operation  be 
designated  as  the  "Callisen-Amussat  operation"  and  thus  honor 
both  surgeons :  one  for  inventing  the  operation  and  the  other 
for  his  efforts  to  popularize  it. 

The  steps  in  a  colostomy  for  the  relief  of  congenital  mal- 
formations differ  so  little  from  those  of  colostomy  for  other 
conditions  that  they  will  be  omitted  here.  They  will,  however, 
be  given  in  detail  in  a  special  chapter  devoted  to  this  subject. 


LITERATURE  ON  CONGENITAL  MALFORMATIONS    (ABNORMALITIES) 
OF  THE  RECTUM 


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CONGENITAL  MALFORMATIONS  89 

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1855. 
Ottinger:    "These  inaugurale  sur  les  Imperf orations  de  I'anus."    Munich,  1826. 
Page:    Boston  Med.  and  Surg.  Jour.,  vol.  Ivii,  p.  239.     Boston,  1857. 
Petit:    M6m.  de  VAcad.  Roy.  de  Chir.  de  Paris,  t.  ii,  Ann§e  1781. 
Pineo:    Boston  Med.  and  Surg.  Jour.,  vol.  Ivii,  p.  284,  1858. 
Richardson:    Philosophical  Trans,  of  the  Roy.  Soc.  of  London,  vol.  vii. 
Richter:     "Chirurgische  Bibliothek."     Gottingen,   1774. 

Schleiss  (von) :   Zeitschrift  fiir  Rationell  Med.,  Bd.  iii,  S.  366.    Heidelberg,  1853. 
Smellie:    "A  Collection  of  Preternatural  Cases,"  etc..  Collect  XL VI,  vol.  iii. 

London,  1774. 
Tungel:    "Ueber  Kiinstliche  Afterbildung."     Kiel,  1853. 
Velpeau:    "Nouveaux  Elements  de  Medecin  Operatoire."    Paris,  1832. 
Waters:    Duhlin  Jour,  of  Medical  Science,  vol.  xxi,  p.  321,  1842. 
West:    "Lect.  on  Dis.  of  Infancy  and  Childhood,"  Lect.  XXXI,  p.  374,  1854. 
York:    Boston  Med.  and  Surg.  Jour.,  vol.  xlii,  p.  273,  1850. 


CHAPTER  VI 

CONSTIPATION 

It  is  doubtful  if  there  is  any  other  ailment  which  is  more 
prevalent,  causes  more  annoyance,  or  is  more  troublesome  to 
both  physician  and  patient  than  persistent  constipation.  It  is 
not  always  easy  to  tell  just  where  healthy  action  of  the  bowel 
ceases  and  constipation  begins.  Physiology  teaches  that  the 
average  healthy  person  should  have  at  least  one  free  alvine 
dejection  in  every  twenty-four  hours;  yet  it  is  an  every-day 
occurrence  to  meet  with  individuals  who  do  not  defecate  more 
than  once  every  two  or  three  days,  and  still  others  who  may 
have  two  stools  daily,  and,  so  far  as  appearances  go,  one  person 
is  just  as  healthy  as  the  other.  Constipation  is  one  of  the  most 
frequent  symptoms  of  rectal  disease,  and  also  one  of  the  most 
common  causes  of  the  same.  In  fact,  it  may  be  either  an  in- 
dependent affection  or  a  symptom  of  some  other  disease. 

ETIOLOGY 

There  are  so  many  causes  of  constipation  that  no  attempt 
will  be  made  to  record  them  all;  only  the  most  common  will 
be  mentioned  under  the  following  headings : — 

1.  Mechanical   obstruction.       3.  Deficiency  of  the  secre- 

2.  Defective  peristaltic  ac-  tions. 

tion.  4.   Sundry  causes. 

Mechanic  Obstniction. — Under  this  heading  are  included 
all  those  causes  which  prevent  free  passage  of  the  feces  along 
the  intestinal  tract,  such  as  stricture,  congenital  or  otherwise; 
hypertrophy  of  the  "rectal  valves"  or  of  the  sphincter  or  le- 
vator ani  muscles;  polyps,  tumors  within  or  external  to  the 
bowel,  intussusception,  enlarged  prostate,  prolapsed  or  retro- 
verted  (Fig.  41)  uterus,  pelvic  inflammations,  etc.  It  has  been 
shown  (see  chapter  on  anatomy)  that  all  the  rectal  coats 
(mucosa,  submucous  layer  of  fibrous  tissue,  and  circular  and 
longitudinal  muscular  coats)  may  enter  into  the  formation  of 
(90) 


CONSTIPATION 


91 


the  "rectal  valves'';  therefore  one  or  more  of  these  "valves" 
may  become  hypertrophied  and  partially  obstruct  the  lumen  of 
the  bowel,  thus  delaying  or  preventing  the  passage  of  feces. 

Defective  Peristaltic  Action. — There  are  many  things  that 
play  their  respective  parts  in  causing  diminished  peristaltic 
action.  Irregular  habits  in  living,  however,  head  the  list,  and 
the  reason  for  this  becomes  at  once  apparent  when  the  act  of 
defecation  is  studied  (see  section  on  "Physiology  of  the  Rec- 
tum"). The  feces  collect  in  the  lower  portion  of  the  sigmoid, 
and  remain  there  until  shortly  before  stool,  when  peristalsis 
begins,  and  they  are  moved  downward  in  the  rectum,  exciting 


Fig.  -11.— Showing  how  the  Uterus  may  Press  the  Rectum  Back  Against  the 
Bony  Structures,   Causing  Partial  Occlusion  and  Constipation. 


the  desire  to  defecate.  If  this  warning  of  the  approach  of  the 
feces  is  appreciated  and  the  contents  of  the  rectum  promptly 
expelled,  all  is  v/ell;  on  the  other  hand,  when  this  impulse  is 
ignored,  the  feces  may  remain  in  the  rectum  or  be  returned 
by  reverse  peristalsis  into  the  sigmoid  (rarely),  where  they 
remain  until  again  moved  downward,  reproducing  the  sensa- 
tion. If  these  sensations  are  ignored  day  after  day,  the  mu- 
cous membrane  soon  loses  its  sensitiveness  and  the  muscular 
coat  its  tonicity,  and,  as  a  result,  large  quantities  of  fecal  matter 
may  accumulate  in  the  sigmoid  or  in  the  rectum  without  ex- 


92  DISEASES  OF  THE  RECTUM  AND  ANUS 

citing  the  least  desire  to  defecate.  Irregular  time  for  eating 
and  improper  diet  are  liable  to  diminish  peristaltic  action;  it 
is  a  well-known  fact  that  foods  containing  very  little  liquid  and 
those  that  leave  httle  residue  are  liable  to  accumulate  in  the 
bowel  and  at  some  time  press  upon  the  nerves  sufficiently  to 
produce  a  partial  paresis. 

Deficiency  of  the  Secretions. — Many  of  the  causes  produc- 
ing diminished  peristaltic  action  are  also  apt  to  lessen  the 
normal  secretions  of  the  bowel.  Again,  the  intestinal  secre- 
tions are  diminished  in  certain  hepatic  diseases  in  which  the 
amount  of  bile  emptied  into  the  bowel  is  deficient  and  also 
when  there  is  inactivity  of  the  intestinal  glands  from  any  cause, 
especially  atrophic  proctitis. 

Sundry  Causes.  —  Under  this  heading  are  included  those 
causes  resulting  from  general  disturbances,  such  as  diabetes, 
melancholia,  insanity,  old  age,  paralysis,  lead  poisoning,  and 
those  that  are  purely  of  local  origin  in  the  terminal  portion  of 
the  colon  and  the  rectum.  In  the  order  of  their  frequency  the 
local  causes  of  constipation  are : — 

1.  Anal  fissure.  3.   Stricture  (benign  or  ma- 

2.  Ulceration.  lignant). 

4.   Polyps. 

Fissure  and  ulceration  cause  constipation,  because  persons 
thus  afflicted  delay  going  to  stool  as  long  as  possible  on  ac- 
count of  the  pain  that  accompanies  and  follows  defecation. 
Stricture  and  polyps  produce  constipation  by  obstructing  the 
passage  of  the  feces. 

SYMPTOMS 

Among  the  symptoms  other  than  irregularity  and  incom- 
pleteness of  the  stools  may  be  mentioned  headache,  inattention 
to  business,  loss  of  memory,  melancholia,  sallow  complexion, 
indigestion,  loss  of  appetite,  etc.,  and  a  long  train  of  nervous 
and  reflex  phenomena.  Perhaps  the  most  common  and  an- 
noying reflex  symptoms  accompanying  constipation  are  fre- 
quent spasmodic  contractions  of  the  external  sphincter  and 
levator  ani  muscles.  Muscular  spasm  is  excited  whenever  the 
fecal  mass  presents  at  the  anal  outlet  and  is  not  promptly  ex- 
pelled. Again,  when  the  feces  collect  in  large  quantities  within 
the  colon,  sigmoid,  or  rectum,  these  muscles  are  kept  in  a 
constant  state   of  irritability,   owing  to  the   insults  to  which 


CONSTIPATION  93 

they  are  subjected  by  the  fecal  mass  and  the  reflex  disturb- 
ances aroused  by  pressure  upon  the  very  sensitive  mucous 
membrane  and  anus.  As  a  result,  the  muscles  become  hyper- 
tropliied  and  very  strong  from  the  additional  work.  Spasm 
of  the  sphincter-muscle  is  frequently  induced  by  the  presence 
of  a  fissure  in  the  mucous  membrane  caused  by  injury  inflicted 
during  expulsion  of  hardened  feces.  Instead  of  aiding  in  the 
act  of  defecation,  the  muscles  now  present  an  obstruction 
beyond  control  of  the  will,  and  aggravate  the  condition.  In 
another  part  of  this  chapter  it  was  stated  that  certain  local 
conditions  of  the  rectum  might  be  accepted  as  causes  of  con- 
stipation. Just  here  it  may  be  remarked  that  the  most  fre- 
quent cause  of  rectal  disease  is  constipation,  and  that  any  one 
of  the  following  local  diseases  of  the  rectum  and  anus  may 
be  a  symptom  of  constipation : — ■ 

1.  Anal  fissure.  4.  Prolapse. 

2.  Ulceration.  5.   Proctitis  and  periprocti- 

3.  Hemorrhoids.  tis. 

6.   Neuralgia. 

Anal  Fissure  is  a  common  symptom  of  constipation.  When 
defecation  has  been  deferred  for  several  days  the  feces  accu- 
mulate; the  watery  portion  is  absorbed;  they  become  dry, 
hard,  nodular  and  very  difficult  to  expel,  frequently  making 
a  rent  in  the  mucous  membrane  and  resulting  eventually  in 
irritable  fissure. 

Ulceration  of  the  Rectum  and  of  the  Sigmoid  is  a  frequent 
symptom  of  persistent  constipation,  because  the  pressure  ex- 
erted upon  the  nutrient  blood-vessels  by  the  fecal  mass  causes 
necrosis  of  the  tissues. 

Hemorrhoids  may  be  produced  by  constipation  in  several 
ways:  first,  by  obstruction  to  the  return  of  venous  blood; 
second,  by  venous  engorgement  of  the  hemorrhoidal  veins 
during  violent  and  prolonged  straining  at  every  stool ;  third, 
as  a  result  of  the  general  laxity  of  the  tissues  in  those  suffer- 
ing from  constipation. 

Prolapse,  partial  or  complete,  of  the  rectum  may  be  caused 
by  straining  or  by  the  downward  pressure  exerted  by  the  fecal 
mass  during  defecation.  Again,  prolapse  may  be  the  result 
of  paresis  of  the  bowel  caused  by  pressure  of  the  feces  upon 
the  nerves. 


94  DISEASES  OF  THE  EECTUM  AND  ANUS 

Proctitis  and  Periproctitis  are  a  frequent  result  of  constipa- 
tion. An  inflammation  of  the  rectum  and  surrounding  tissues, 
that  may  or  may  not  terminate  in  abscess  and  fistula,  some- 
times follows  injury  to  the  very  sensitive  mucosa  by  the  hard- 
ened feces;  furthermore,  when  the  feces  are  retained  for  a 
long  time  any  unsound  portion  of  the  mucous  membrane  is 
exposed  to  the  many  septic  organisms  contained  in  them. 

Neuralgia  of  the  Rectum  may  sometimes  result  from  press- 
ure of  the  fecal  mass  upon  neighboring  nerves,  causing  reflex 
pains  in  the  region  of  the  sacrum  and  coccyx;  such  pains  are 
usually  diagnosticated  as  neuralgia  of  the  rectum. 

In  addition  to  the  diseases  just  enumerated,  constipation 
may  aggravate  any  other  disease  of  the  rectum  or  colon.  It 
is  at  once  obvious  that  the  treatment  of  constipation  should 
be  perfectly  understood  by  all  who  confine  their  practice  to 
rectal  and  anal  diseases. 

TREATMENT 

Much  has  been  written  concerning  the  treatment  of  this 
annoying  condition,  and  a  host  of  remedies  have  been  recom- 
mended for  its  relief,  none  of  which  has  proven  satisfactory. 
This  is  largely  due  to  the  fact  that  too  much  reliance  has  been 
placed  on  cathartics,  purgatives,  and  injections,  and  too  little 
attention  given  to  diet  and  the  establishment  of  regular  habits 
in  eating,  exercising,  sleeping,  and  attending  to  the  calls  of 
nature.  Again,  local  disease  of  the  rectum  which  induces  or 
aggravates  constipation  is  often  overlooked  or  ignored  in  the 
treatment.  All  who  have  treated  many  cases  of  constipation 
must  have  noticed  how  quickly  the  remedies  prescribed  for  its 
relief  lose  their  power.  The  dose  has  to  be  repeated  or  a  new 
drug  substituted;  in  a  short  time  another  must  be  selected, 
and  so  on  until  both  patient  and  physician  are  discouraged. 
For  a  number  of  years  the  writer  has  not  used  medicine  in  the 
treatment  of  constipation,  and  the  results  have  been  markedly 
better  since  he  adopted  this  plan.  He  does  not  wish  to  con- 
vey the  impression  that  he  can  cure  all  cases  of  constipation 
without  medication;  but  he  is  confident  <"hat  almost  every  case 
can  be  benefited,  and  a  very  large  percentage  entirely  cured, 
by  other  means :  a  fact  that  he  has  often  demonstrated  in  private 
and  dispensary  practice.  The  plan  followed  he  has  designated  the 
non-medicinal  method. 


CONSTIPATION  95 

NON=MEDICINAL   METHOD 

The  author  first  called  attention  to  this  method  of  treat- 
ment at  the  Kansas  City  Academy  of  Medicine  in  January, 
1891.  Then  before  the  Jackson  County  (Mo.)  Medical  So- 
ciety in  February,  1892;  next  at  the  Missouri  Valley  Medical 
Society  at  St.  Joseph,  Mo.,  March  16,  1893.  The  paper  last 
mentioned  appeared  in  the  Medical  Herald  the  same  month. 
The  suggestion  came  to  him  through  operations  for  the  relief 
of  certain  pathologic  conditions  about  the  anus  wherein  the 
external  sphincter-muscle  had  been  divulsed  to  insure  complete 
rest.  The  patients  frequently  remarked  that  they  also  had 
been  cured  of  their  constipation.  At  first  the  author  did  not 
understand  how  this  occurred;  after  studying  the  matter 
closely,  however,  the  conclusion  was  reached  that  it  must  be 
due  to  the  dilatation,  and,  on  referring  to  Allingham's  work 
on  rectal  diseases,  it  was  found  that  he  had  had  the  same  ex- 
perience, and  advised  divulsion  as  one  of  the  essential  features 
in  the  treatment  of  constipation.  The  author  then  tried  divul- 
sion in  a  number  of  old  cases  of  constipation  that  he  had 
attempted  to  cure  by  medication;  the  results  were  very  satis- 
factory, but  not  all  that  had  been  hoped  for.  In  some  the 
benefit  was  permanent,  while  in  others  it  was  only  temporary; 
this  led  to  the  conclusion  that  other  features  must  be  added 
to  the  treatment  in  order  to  successfully  combat  this  annoying 
condition.  After  experimenting  with  a  large  number  of  cases 
the  following  features  were  added.  These  are  practiced  as  a 
routine  after  any  local  condition  that  might  aggravate  the 
costiveness  has  been  corrected : — 

1.  Divulsion  of  the  sphincter. 

2.  Frequent  rectal  and  abdominal  massage. 

3.  Copious  injections  of  warm  water  (in  the  beginning 
only). 

4.  Application  of  electricity  over  the  abdomen  and  in  the 
rectum. 

In  addition  to  this  part  of  the  treatment,  which  must  be 
carried  out  by  the  physician,  the  patient  must  observe  the  fol- 
lowing rules : — 

1.  Go  to  stool  daily  and  as  near  the  same  hour  as  is  con- 
venient. 

2.  Correct  errors  in  diet. 

3.  Drink  an  abundance  of  water  and  eat  sufficient  fruit. 


9Q  DISEASES  OF  THE  RECTUM  AND  ANUS 

4.  Take  plenty  of  out-door  exercise. 

5.  Take  a  cold  bath  every  morning,  followed  by  thorough 
rubbing. 

6.  Dress  warmly  in  winter  and  coolly  in  summer. 

7.  Change  occupation  or  climate  if  the  case  demands  it. 

8.  Be  temperate  in  all  things  affecting  the  general  health. 
Divulsion. — When  constipation  is  induced  or  made  worse 

by  an  hypertrophied  sphincter  or  a  spasm  of  the  same  from 
any  cause,  thorough  divulsion  should  be  practiced  at  the 
earliest  opportunity,  and  great  care  must  be  taken  not  to 
lacerate  the  muscle.  The  author  has  treated  several  cases  of 
complete  incontinence  caused  by  too  rapid  and  careless  divul- 
sion of  the  sphincter.  Dilatation  can  be  accomplished  by  either 
immediate  (forcible)  or  gradual  divulsion.  The  first  should  be 
done  under  general  anesthesia  by  inserting  the  two  thumbs  into 
the  anus  and  stretching  the  muscle  thoroughly  in  every  direc- 
tion until  there  is  no  resistance.  Many  dilators  have  been 
devised  for  this  purpose,  but  none  of  them  possesses  any  ad- 
vantage over  the  fingers,  and  are  most  apt  to  tear  the  muscle  or 
injure  the  mucous  membrane.  Gradual  divulsion  is  practiced 
in  cases  in  which  an  anesthetic  is  either  deemed  unsafe  or  the 
patient  refuses  to  take  it;  it  can  be  accomphshed  by  the  fingers 
or  any  of  the  many  forms  of  rectal  bougies.  The  author  prefers 
the  soft-rubber  bougies  (Wales's),  which  can  be  had  in  any  size. 
The  Wales  bougies  are  about  twelve  inches  (3  decimeters)  in 
length,  and  have  a  central  channel  through  which  the  colon 
and  the  rectum  can  be  irrigated  if  necessary.  They  are  better 
than  the  short  Pratt  or  "Ideal"  dilators,  because,  in  addition 
to  dilating  the  sphincter,  they  seem  to  act  as  a  stimulus  to  the 
mucous  membrane,  reach  higher  up  the  bowel,  and  excite  re- 
newed peristaltic  action.  It  is  better  to  commence  with  a  small 
size, — say,  a  No.  6, — leave  it  in  a  few  minutes  until  the  muscle 
becomes  accustomed  to  it;  a  larger  size  may  then  be  selected, 
and  so  on  until  a  No.  12  can  be  introduced  with  ease. 

It  is  better  to  do  too  little  than  too  much  at  the  first 
sitting.  Sometimes  the  sphincter  is  very  stubborn  and  requires 
careful  handling  or  its  irritability  will  be  increased.  Patients 
come  to  the  office  two  or  three  times  each  week,  the  bougies 
are  introduced  and  allowed  to  remain  within  the  bowel  until 
sphincter  resistance  is  overcome,  and  many  times  their  withdrawal 
will  soon  be  followed  by  a  copious  stool.     Forcible  divulsion  is 


CONSTIPATION  97 

seldom  required  more  tJian  once  if  a  large-sized  bougie  is  used 
from  time  to  time  afterward,  just  as  in  gradual  divulsion. 
When  thorough  dilatation  has  been  accomplished,  the  muscle, 
instead  of  acting  as  an  impassable  barrier  to  the  discharge  of 
the  feces,  now  offers  only  passive  resistance,  but  sufhciently 
strong,  however,  to  prevent  any  unpleasant  accidents,  yet  not 
strong  enough  to  resist  the  power  of  the  expulsory  muscles 
when  the  latter  are  brought  into  full  play  during  defecation. 
Large  quantities  of  feces  do  not  now  accumulate ;  consequently 
the  pressure  upon  the  mucous  membrane  and  neighboring 
nerves  is  eliminated,  and  the  bowel  regains  its  normal  sensi- 
bility and  tonicity. 

Abdominal  Massage.  —  This  is  one  of  the  most  essential 
features  in  the  treatment  of  habitual  constipation.  Massage 
is  quite  ancient,  having  been  practiced  by  Hippocrates.  It 
was  not  until  recently,  however,  that  physicians  at  home  and 
abroad  recognized  in  it  a  powerful  remedial  agent  when  prop- 
erly applied,  and  gave  it  their  scientific  attention,  thereby 
wresting  it  from  the  hands  of  "charlatans"  and  "robbers,"  by 
whom  its  practice  had  long  been  controlled.  The  author  has 
employed  it  extensively  during  the  last  ten  years  in  connection 
with  other  features  mentioned  in  the  treatment  of  constipation, 
and  has  found  it  to  be  a  most  valuable  adjunct. 

Procedure. — The  patient  is  placed  in  the  recumbent  posi- 
tion upon  a  table  which  can  be  so  manipulated  that  the  head 
may  be  raised  or  lowered,  the  body  rotated  from  side  to  side, 
and  the  intestines  changed  from  one  position  to  another. 
Gentle,  but  finn,  pressure  is  then  made  with  the  palm  of  the 
hand  and  the  ball  of  the  thumb,  over  the  large  intestine,  be- 
ginning in  the  right  iliac  fossa.  The  course  of  the  colon  is 
followed  into  the  left  iliac  fossa,  accompanying  the  pressure 
by  kneading  the  parts  thoroughly  with  the  fingers.  This  pro- 
cedure should  be  repeated  several  times,  and  occupy  in  all 
about  ten  or  twelve  minutes.  In  the  beginning  the  massage 
should  be  practiced  every  other  day ;  later  on  in  the  treat- 
ment twice  a  week  will  sui^ce.  Massage  of  the  rectum  should 
be  practiced  also. 

Besides  massage  of  the  large  intestine,  special  massage 
must  be  given  to  the  liver  and  small  intestine  when  the  amount 
of  bile  and  intestinal  secretions  is  diminished.  The  patient 
cannot  give  himself  massage,  because  every  effort  on  his  part 


98  DISEASES  OF  THE  RECTUM  AND  ANUS 

will  be  followed  by  contraction  of  the  abdominal  muscles,  which 
prevents  deep  manipulations.  If  a  patient  is  unable  to  pay  for 
the  treatments,  the  author  would  recommend,  as  do  the  German 
physicians,  that  he  take  a  metal  ball  or  one  of  those  used  for 
bowling,  weighing  from  three  to  five  pounds  (1.5  to  2.3  kilo- 
grams), covered  with  cloth  to  prevent  chilling  the  skin,  and 
while  in  the  recumbent  position  roll  it  daily  over  the  course  of 
the  colon. 

Mamtal  or  vibratory  massage  renders  valuable  assistance  in 
the  treatment  of  constipation  in  several  ways  : — 

1.  It  improves  the  circulation  and  stimulates  the  nerve- 
centers  to  renewed  action. 

2.  It  loosens  adhesions  and  dislodges  and  breaks  up  fecal 
impaction. 

3.  It  restores  tone  to  fatigued  and  inactive  muscular  fibers. 

4.  It  excites  the  liver  and  intestinal  glands  to  renewed 
action. 

5.  Altogether  it  assists  in  establishing  normal  peristalsis. 

Copious  "Warm-Water  Injections.  —  In  beginning  the  treat- 
ment of  constipation,  especially  where  the  feces  have  become 
impacted,  much  benefit  can  be  derived  from  the  proper  admin- 
istration of  copious  injections  of  warm  water;  they  soften  any 
fecal  mass  that  might  be  lodged  in  the  bowel  and  facilitate  its 
discharge.  Flushing  the  rectum  alone  does  not  suffice ;  on  the 
contrary,  the  colon  should  also  be  reached,  since  the  feces  fre- 
quently become  impacted  in  the  latter  situation. 

To  do  this  well  a  colon-tube  from  eighteen  to  twenty-four 
inches  (46  to  61  centimeters)  in  length  and  a  good  syringe — • 
preferably  a  Davidson  bulb,  hard-rubber  piston,  or  a  fountain, 
the  nozzle  of  which  can  be  inserted  into  the  tube — are  required. 
The  syringe  is  then  filled  and  the  patient  placed  in  the  Sims 
or  recumbent  position.  When  the  tube  has  been  well  oiled 
with  some  stiff  lubricant,  it  is  passed  slowly  and  gently  up  the 
bowel  until  it  becomes  lodged  beneath  Houston's  "valves."  A 
few  ounces  of  water  are  then  forced  through  it,  and  at  the  same 
time  pressure  is  made  upward  with  the  tube ;  by  these  means 
the  "valve"  will  be  lifted  upward  out  of  the  way  each  time  the 
tube  meets  with  resistance ;  the  procedure  must  be  repeated 
until  the  tube  is  well  within  the  colon.  The  syringe  is  then 
attached  and  the  water  allowed  to  run  until  the  colon  is  dis- 
tended.    This  will  require  anywhere  from  a  quart  (1  liter)  to  a 


CONSTIPATION  99 

gallon  (4  liters)  or  more  of  warm  water,  depending  upon  the 
amount  of  feces  present.  The  water  should  be  retained  as  long 
as  possible,  in  order  to  permeate  the  mass.  The  injections 
should  be  repeated  daily  when  indicated  until  all  the  offending 
feces  have  been  removed  and  normal  peristalsis  and  glandular 
secretion  have  been  re-established,  when  they  should  be  dis- 
continued. 

It  has  been  demonstrated  frequently  that,  when  normal 
defecation  is  interfered  with  by  the  continuous  daily  injections 
of  water  (Hall  treatment),  the  bowel  makes  no  attempt  to  get 
rid  of  the  contents,  but  patiently  awaits  the  convenience  of  the 
interested  person  and  the  injection,  which  relieve  it  of  all 
responsibihty. 

When  soap-suds  enemata  are  indicated,  green  or  soft  soap 
(saponis  viridis),  and  not  ordinary  or  hard  soap,  should  be 
used,  because  the  former  is  more  reliable,  and  produces  fewer 
constitutional  disturbances  than  the  latter.  Bolton^  has  re- 
cently shown  conclusively  that  "rashes"  are  quite  common  after 
the  administration  of  injections  containing  hard  soap,  and, 
further,  that  such  eruptions  rarely,  if  ever,  follow  .?o/^-soap 
enemata.  His  conclusions  are  based  on  a  study  of  nine  hun- 
dred and  three  enemata  given  to  five  hundred  patients.  He 
says :  "All  the  rashes  appeared  on  the  day  following  the  in- 
jection, and  their  duration  was  from  one  to  three  days.  They 
consisted  in  each  case  of  fine,  thickly-sown  papules,  which 
either  gave  rise  to  a  coarsely  punctate  appearance  or  fused  into 
well-defined  patches,  mixed  with  patches  of  simple  erythema. 
In  one  case  urticarial  wheals  were  present.  In  some  cases  the 
whole  body  was  more  or  less  uniformly  covered ;  in  others  the 
rash  was  chiefly  apparent  on  the  buttocks  and  extensor  sur- 
faces of  the  limbs,  or  on  the  trunk,  especially  at  the  sides." 

Electricity. — Electricity  has  been  highly  recommended  by 
many  writers  on  the  treatment  of  constipation.  The  author 
has  used  with  varied  success  both  the  galvanic  and  faradic  cur- 
rents. One  pole  may  be  placed  over  the  spinal  column  and  the 
other  moved  about  over  the  course  of  the  colon,  or  one  over 
the  spine  and  the  other  within  the  rectum.  The  strength,  fre- 
quency of  application,  and  duration  of  the  current  should  be 
changed  to  suit  the  case.  As  yet,  the  author  has  not  been  con- 
vinced that  electricity  alone  is  sufficient  to  cure  very  persistent 


'Bolton,  "Eaema  Rashes,"  The  ClinicalJournal,  London,  xix,  p.  176,  1902. 


100  DISEASES  OF  THE  RECTUM  AND  ANUS 

cases  of  constipation,  but  he  is  certain  that  much  benefit  can 
be  had  from  its  use  in  conjunction  with  divulsion,  massage,  etc. 
Its  action  is  similar  to  that  of  massage,  in  that  it  restores  mus- 
cular tone  and  glandular  activity. 

The  features  of  the  treatment  just  referred  to  should  be 
carried  out  by  the  physician,  while  those  to  follow  are  to  be 
practiced  by  the  patient  under  the  supervision  of  the  attendant. 

Patients  should  go  to  stool  daily  at  the  same  hour  (preferably 
just  after  the  morning  meal).  This  may  seem  unimportant, 
but  experience  has  shown  that  the  bowel  can  be  educated  to 
act  at  the  same  hour  daily;  or,  on  the  other  hand,  not  more 
than  once  in  two  or  three  days  in  those  who  are  careless  in 
their  habits.  This  may  not  be  accomplished  at  fi,}'st  in  those 
who  have  persistent  constipation;  but,  if  these  subjects  will 
persevere  in  going  to  the  closet  at  or  near  the  same  time  every 
day,  and  devote  their  entire  time  while  there  to  the  expulsion 
of  the  fecal  contents,  and  not  make  it  a  reading-room,  they  will 
bring  about  the  desired  result.  Patients  are  apt  to  become 
discouraged  at  first;  they  should  be  informed  that  the  ulti- 
mate result  of  the  treatment  is  not  influenced  by  failure  of  the 
bowel  to  act  regularly  during  the  first  few  days. 

Correction  of  Errors  in  Diet. — This  is  one  of  the  most  es- 
sential features  in  the  treatment.  All  foods  known  to  disagree 
with  patients  should  be  discarded.  No  attempt  will  be  made 
to  lay  down  a  fixed  diet;  suffice  it  to  say  that  it  should  con- 
sist as  far  as  possible  of  easily-digestible  foods,  intermediate 
between  meat  and  milk.  In  children  the  diet  should  be  pro- 
portionately rich  in  fats,  albuminoids,  and  sugars,  but  poor 
in  starches.  A  reasonable  amount  of  fruit — such  as  apples, 
oranges,  and  figs — should  be  allowed;  they  will  do  much 
toward  reHeving  the  constipated  condition.  Meals  should  be 
taken  at  regidar  hours  and  under  pleasant  surroundings ;  it  has 
been  observed  that  digestion  is  more  or  less  interfered  with 
during  anger  and  sorrow. 

Drink  an  abundance  of  water.  There  are  few  better  laxa- 
tives than  a  glass  of  cold  or,  preferably,  Jwt  water,  taken  upon 
an  empty  stomach  before  breakfast.  Water  prevents  the  feces 
from  becoming  dry  and  impacted  and  stimulates  peristalsis. 

Out-door  Exercise.  —  Persons  suffering  from  constipation 
should  take  regular  out-door  exercise ;  and,  if  convenient  to 
a  gymnasium,  they  should  be  requested  to  spend  half  an  hour 


CONSTIPATION  101 

each  day  developing  the  various  muscles  of  the  body.  It  is 
undoubtedly  true  that  the  Germans,  who  are  noted  for  their 
out-door  sports  and  gymnastics,  suffer  much  less  from  consti- 
pation than  the  Americans,  who  devote  but  little  time  to  such 
sports  and  exercises. 

Bathing. — The  best  time  to  bathe  is  before  breakfast.  The 
colder  the  water,  the  better ;  the  bath  should  be  followed  by  a 
thorough  rubbing  of  the  skin  with  a  Turkish  towel.  This  stim- 
ulates the  circulation,  and  opens  up  the  pores  of  the  skin. 
Altogether  one  feels  hke  a  "new  man"  and  ready  to  undertake 
the  arduous  duties  before  him  for  the  day. 

Clothing. — It  is  a  well-known  fact  that  cold  is  conducive 
to  constipation  and  warm  weather  to  diarrhea;  hence  it  is 
very  essential  that  these  patients  should  dress  warmly  in  winter 
and  coolly  in  summer. 

Business  and  Location.  —  In  some  cases  of  persistent  con- 
stipation, when  all  other  means  have  failed  to  be  of  any  benefit, 
change  of  vocation  and  residence  is  absolutely  essential.  It  is 
a  recognized  fact  that  a  sedentary  occupation  is  a  frequent 
cause  of  constipation,  and  that  a  change  to  a  more  active  pur- 
suit in  the  open  air  will  sometimes  cure  it;  further,  persons 
who  suffer  from  constipation  in  one  climate  are  relieved  when 
they  change  to  another.  Admitting  these  to  be  facts,  it  is 
justifiable,  in  certain  very  obstinate  cases,  to  advise  the  patient 
to  move  to  another  climate  or  change  his  occupation  or  both. 

Temperance  in  all  things  affecting  the  general  health.  Ex- 
cesses and  irregularities  in  living  play  an  important  role  in 
producing  and  prolonging  constipation;  hence,  moderation  in 
the  manner  of  living  should  be  encouraged. 

Up  to  the  time  of  publication  of  the  first  edition  of  this 
work  (1896)  the  author  had  treated  250  cases  of  obstinate  con- 
stipation by  the  "non-medicinal  method."  Of  this  number  140 
were  females  and  110  males,  their  ages  ranging  from  infancy 
to  85  years.  The  following  table  will  show  the  results  of  the 
treatment : — 

Table  IV.    Two  Hundked  and  Fifty  Cases  of  Constipation 
Treated  by  the  Non-medicinal  Method 

Cured   150 

Markedly  improved   60 

Slightly   improved    15 

Unimproved    25 

Total    250 


102  DISEASES  OF  THE  RECTUM  AND  ANUS 

Since  1896  he  has  treated  several  hundred  additional  cases 
by  the  same  or  other  methods  described  below,  and  the  results 
have  been  equally  as  good,  if  not  better.  At  an  early  date  the 
writer  purposes  publishing  a  treatise  on  constipation  and  diar- 
rhea and  their  local  treatment. 

SURGICAL  TREATMENT 

It  is  sometimes  necessary  to  resort  to  surgical  pro- 
cedures in  the  treatment  of  constipation.  In  some  cases  the 
sphincter-muscle  becomes  greatly  hypertrophied  and  so  rigid 
that  it  is  impossible  to  secure  the  necessary  amount  of  relaxa- 
tion by  divulsion,  however  thoroughly  the  latter  is  done.  There 
is  but  one  way  to  overcome  this  obstacle,  namely:  by  complete 
division.^  This  is  done  by  passing  a  bistoury,  guided  by  the 
index  finger,  well  above  the  sphincter  and  then  withdrawing  it, 
completely  dividing  the  muscle  in  the  posterior  median  line. 
The  after-treatment  of  the  wound  thus  made  is  the  same  as 
that  following  fistula  operations.  The  author  has  performed 
this  operation  fifteen  times,  and,  combined  with  the  measures 
described  above,  the  results  have  been  entirely  successful. 
Divulsion  is  always  preferable,  except  in  extreme  cases  where 
the  sphincter-muscle  is  hypertrophied  and  very  rigid. 

The  levatores  ani  embrace  the  rectum  in  a  sort  of  fork  at 
the  upper  end  of  the  anal  canal,  and,  as  a  result  of  the  constant 
pressure  exerted  upon  these  muscles  by  the  fecal  mass,  they 
occasionally  become  hypertrophied,  and  must  be  considered  in 
the  treatment  of  constipation.  The  author  has  in  three  cases 
found  it  necessary  to  sever  the  attachment  of  the  levators  ani 
to  the  coccyx  by  a  subcutaneous  tenotomy;  in  two  other  cases 
the  same  end  was  accomplished  by  means  of  a  posterior  me- 
dian incision  exposing  the  coccyx,  which  was  then  elevated 
with  a  strong,  dull-pointed  hook  caught  under  its  tip,  and  thus 
held  while  the  attachment  of  the  levator  ani  was  severed.  The 
hook  was  then  removed  and  the  external  wound  closed  by  a 
sufficient  number  of  interrupted  catgut  sutures.  When  the 
posterior  bony  attachment  of  the  levatores  ani  muscles  have 
been  destroyed,  they  no  longer  contract  about  the  rectum  suf- 
ficiently to  obstruct  the  passage  of  the  feces.  The  author 
treated  one  case  in  which  the  hypertrophied  levator  ani   mus- 

'  In  most  instances,  this  operation  should  be  performed  under  local  anesthesia.  See, 
Chapter  XLI. 


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CONSTIPATION  103 

cles  could  be  distinctly  outlined  by  the  finger  in  the  rectum, 
especially  when  the  patient  was  requested  to  draw  the  anus 
upward;  severing  of  the  coccygeal  attachment  in  this  case  gave 
no  relief,  and  a  myotomy  was  subsequently  made. 

This  operation  was  performed  as  follows :  Through  a 
posterior  median  incision  extending  from  the  lower  end  of  the 
sacrum  to  within  half  an  inch  (1.27  centimeters)  of  the  anus 
the  coccyx  was  removed,  and  the  muscles  severed  on  either  side 
at  the  point  where  they  cross  the  rectum.  That  portion  of  the 
muscles  which  had  extended  from  the  rectum  to  the  coccyx  was 
detached  from  the  rectum  and  removed.  The  external  wound 
was  then  closed  with  interrupted  catgut  sutures  and  dressings 
applied.  The  patient  promptly  recovered  from  the  operation, 
and  was  gradually  relieved  of  his  constipation. 

None  of  the  above  operations  should  be  employed  except 
as  a  dernier  ressort.  Thus  far  no  unpleasant  sequels  have  fol- 
lowed the  above  procedures.  As  far  as  the  author  is  aware,  the 
operations  above  suggested  for  the  relief  of  obstinate  constipa- 
tion due  to  hypertrophied  sphincter  or  levator  ani  muscles  are 
here  recorded  for  the  first  time. 

When  one  or  more  of  the  "rectal  valves''  become  so  hyper- 
trophied as  to  obstruct  the  passage  of  the  feces,  ''valvotoniy"  is 
indicated.  The  author  has  performed  "valvotomy"  sixty  times, 
and  in  each  instance  the  operation  has  been  followed  by  complete 
cure  or  marked  improvement.  These  good  results,  however, 
could  not  be  attributed  to  "valvotomy"  alone,  as  the  operation 
in  most  instances  was  combined  with  the  non-medicinal  measures 
described  elsewhere. 

In  performing  "valvotomy"  it  is  necessary  to  divulse  the 
sphincter  sufdciently  to  allow  tlie  introduction  of  a  very  large 
proctoscope.  It  is  not  improbable  that  in  many  of  these  cases 
stretching  of  the  sphincter  aided  materially  in  relieving  the  con- 
stipated condition,  together  zvith  the  establishment  of  regular 
habits.  Again,  the  improvement  may  be  due  to  an  active  peri- 
stalsis secondary  to  an  irritation  induced  by  the  clamp,  incision, 
or  subsequent  ulceration  and  proctitis. 

Of  the  60  cases  above  referred  to,  in  51  the  "valves"  were 
divided  with  the  author's  "valve" -clamps  and  in  9  by  Martin's 
operation.  In  all  but  9  the  "valve"  located  upon  the  anterior 
rectal  wall  at  the  base  of  the  bladder  (Kohlrausch's  fold)  was 
the  chief  offending  "valve"  requiring  division.     In  6  the  "valve" 


104  DISEASES  OF  THE  RECTUM  AND  ANUS 

situated  above  this  one  on  the  left  wall  was  divided,  and  in 
only  3  cases  was  it  found  necessary  to  divide  more  than  two 
"valves,"   the  lowermost  two  being  the   ones  usually  affected. 

DIVISION   BY   THE   AUTHOR'S   CLAMP 

The  idea  of  dividing  the  "valves"  by  pressure-necrosis  was 
suggested  to  the  author  by  Pennington,  who  has  devised  a  clip 
for  this  purpose.  Working  with  this  idea  in  view,  the  author 
has  perfected  the  applicator  and  valve-clamp  shown  in  Plate 
IX.  The  first  clamps  made  (Plate  IX,  h  and  c)  were  non- 
fenestrated, about  one-tenth  of  an  inch  (2.5  millimeters)  in 
width,  and  constructed  for  divisions  of  the  "valve"  only.  Later 
the  fenestrated  clamps  (A  and  A')  one  inch  (2.54  centimeters) 
in  length,  and  varying  in  width  from  one-fourth  (6.25  millime- 
ters) to  one-half  inch  (1.27  centimeters),  were  devised  for  biting 
out  a  piece  of  the  "valve,"  and  this  larger  clamp  has  proven  the 
more  satisfactory.  In  order  to  facilitate  their  application  these 
clamps  are  made  in  two  forms,  one  opening  from  above  down- 
ward and  the  other  from  side  to  side.  The  forceps-applicator  and 
clamps  are  so  well  shown  in  the  drawings  that  further  descrip- 
tion of  them  is  unnecessary. 

Division  of  the  "valves"  with  these  clamps  renders  the 
operation  very  simple.  The  technic  is  as  follows :  After  the 
rectum  has  been  thoroughly  cleansed,  place  the  patient  in  the 
knee-chest  posture  and  divulse  the  sphincter  with  Kelly's  conic 
dilator.  A  large  proctoscope  of  suitable  length  is  now  intro- 
duced, and  the  rectum  allowed  to  become  inflated,  exposing  the 
"valves."  The  proctoscope  is  so  adjusted  that  the  "valve"  to 
be  divided  crosses  in  front  of  it  at  a  right  angle.  A  clamp 
to  which  a  long  thread  has  been  attached  is  placed  in  the 
applicator  and  the  screw  so  adjusted  that  it  remains  open.  The 
instrument  is  then  introduced  through  the  proctoscope  and  the 
clamp  slipped  over  the  "valve,"  when  the  screw  in  the  end  of 
the  applicator  is  turned  to  the  left  until  the  clamp  closes  on 
the  "valve"  and  is  freed.  (Plate  X.)  The  proctoscope  is  now 
removed  and  the  string  left  hanging  out  of  the  rectum  to  pre- 
vent the  clamp  being  carried  upward  by  reverse  peristalsis  when 
it  has  cut  is  way  out.  The  entire  operation  may  be  completed 
in  five  minutes.  Depending  upon  the  amount  of  fibrous  tissue, 
it  requires  from  four  to  six  days  to  slough  out,  during  which 
time  the  patient  suffers  but  little,  if  any,  pain.  Usually  the 
writer   requires   the   patient   to    remain   quiet   until   the   clamp 


PLMTE  X 


Gant's  DpBration  af  "  I/alvatamy,"  showing  Mannsr  of  Using  his  Now  Forceps 
Rpplicatar  and  "  UaluE" -clamps.  One  Clamp  is  in  Position  and  /Inathsr 
Placed  Dver  a  "  UalvB  "  Ready  to  be  Freed  from  the  Upphcatar. 


CONSTIPATION  105 

comes  away.  Not  infrequently,  however,  the  operation  has 
been  done  in  his  oi^ce  and  the  patient  allowed  to  resume  his 
usual  duties,  and  no  ill  effects  were  observed.  The  patient  is 
restricted  to  a  semisolid  diet,  and  instructed  to  examine  the 
stools  until  the  clamp  is  found.  After  the  clamp  has  come 
away,  examination  of  the  rectum  will  reveal  that  the  "valve" 
now  stands  out  less  prominently,  and  is  divided  by  a  rounded, 
V-shaped  wound.  The  after-treatment  consists  in  securing 
daily  semisolid  stools  and  irrigation  of  the  wound  with  anti- 
septic solutions. 

The  advantages  of  the  clamp  over  the  cutting  operation 
are  as  follows : — 

1.  No  anesthetic  is  required. 

2.  It  is  bloodless. 

3.  It  is  painless. 

4.  It  is  less  difhcult,  and  can  be  performed  in  a  shorter 
time. 

5.  It  requires  fewer  instruments. 

6.  The  patient  is  not  necessarily  confined  to  his  bed,  and 
suffers  but  little,  if  any,  pain. 

7.  There  is  no  danger  of  peritonitis. 

8.  No  dressings  are  required. 

9.  Recovery  is  more  prompt. 

10.  It  gives  better  results,  because  a  large  section  of  the 
obstructing  "valve"  is  removed. 

Martin's  Operation. — In  so  far  as  the  writer  has  been  able 
to  learn,  Martin^  was  the  first  to  suggest  "valvotomy"  for  the 
relief  of  constipation.    He  describes  the  operation  as  follows : — ■ 

"The  patient  should  be  placed  in  the  proper  posture 
(Fig.  26)  and  the  proctoscope  introduced  and  given  into  the 
hand  of  an  assistant.  The  'valve'  should  now  be  seized  by  te- 
naculums on  either  side  of  the  point  selected  for  section.  The 
knife  should  be  made  to  transfix  the  fibrous  border  of  the  'valve' 
and  to  divide  a  few  fibers  of  this  tissue  and  the  mucous  mem- 
brane covering  it,  by  cutting  its  way  through  the  'valve's'  free 
border.  This  should  be  transfixed  with  the  bistoury  at  a  mo- 
ment when  the  'valve'  is  situated  at  a  right  angle  to  the  gut- 
wall.  Caution :  If  the  'valve'  be  pulled  dowmvard  by  means  of 
the  tenaculums  so  that  it  presents  an  inclined  plane  toward  the 

^Philadelphia  Medical  Journal,  August,   volume  i,  page  421,  1899. 


106  DISEASES  OF  THE  RECTUM  AND  ANUS 

Operator  at  the  moment  when  the  bistoury  is  made  to  transfix 
the  conjoined  tendon,  the  superior  dense  fibrous  lamina  will 
have  a  tendency  to  force  the  knife  outward  and  through  the 
gut-wall;  hence  the  necessity  of  a  proctoscope  of  different 
length  for  each  "valve,"  that  the  proctoscope's  end  may  be  car- 
ried to  the  "valve"  instead  of  the  "valve"  being  pulled  down  to 
the  proctoscope  and  probably  to  disaster.  But  a  few  fibers  of 
the  conjoined  tendon  are  to  be  divided  by  the  bistoury.  After 
the  incision  is  thus  started,  a  scalpel-like  knife,  provided  with  a 
similarly  bent  handle,^  should  be  used  to  deepen  the  incision. 
In  two  places  the  "valve"  should  be  cut.  The  instant  the  con- 
joined tendon  is  divided  a  gaping  wound  will  be  presented  to 
the  eye.  This  wound  is  irregularly  pyramidal,  and  open  at  its 
apex ;  the  two  walls  running  away  from  the  apex  consist  of 
the  fibrous  laminas  of  the  "valve" ;  the  base  is  made  of  the  cir- 
cular muscular  fibers ;  external  to  the  circular  muscular  fibers 
are  the  longitudinal  muscular  and  the  peritoneal  coats  of  the 
rectum.  Should  hemorrhage  occur,  it  may  be  readily  stopped 
by  the  temporary  application  of  clamps." 

In  his  earlier  operations  Martin  allowed  the  wound  to  heal 
by  granulation,  but  more  recently  he  has  adopted  the  plan  of 
closing  the  wound  in  the  mucous  membrane,  in  order  to  secure 
primary  union.  The  sutures  used  are  catgut,  and  are  intro- 
duced by  means  of  a  specially-devised  curved  needle  joined  at 
an  angle  with  a  handle  and  having  an  eye  near  its  point;  this 
needle  is  passed  down  through  one  edge  of  the  mucosa  and 
brought  up  through  the  other,  when  it  is  threaded  with  the 
catgut  by  means  of  a  long-handled  forceps;  it  is  then  with- 
drawn, carrying  the  suture,  which  is  finally  secured  with  perfo- 
rated shot.  In  this  manner  a  sufficient  number  of  sutures  are 
inserted  to  close  the  wound.  The  operation  is  completed  by 
tamponing  the  rectum  with  non-absorbent  cotton  dusted  over 
with  iron  sulphate  to  arrest  bleeding  and  prevent  infection. 
The  patient  is  then  placed  in  bed,  with  feet  elevated,  and  ice- 
bags  are  applied  to  the  lower  spine. 

The  apparent  disadvantages  of  the  cutting  operation  are : — 
1.  Number  of  instruments  necessary,  the  great  difficulty 
of  performing  the  operation,  and  the  length  of  time  required 
for  it. 


1  The  knives  used  have  handles  adjusted  at  such  an  angle  as  not  to  obstruct  the 
operator's  view. 


CONSTIPATION  107 

2.  Danger  of  hemorrhage  during  and  after  operation. 

3.  Increased  pain  caused  by  inflammation  about  the  wound 
and  retention  of  gases  due  to  tamponing. 

4.  Danger  of  infection,  common  to  closed  wounds  in  this 
region. 

5.  Confinement  of  the  patient  in  bed  for  a  considerable 
length  of  time. 

6.  No  part  of  the  obstructing  "valve"  is  removed. 

7.  Finally,  in  the  author's  experience,  the  results  derived 
from  "valvotomy"  by  the  cutting  method  have  not  been  as 
prompt  or  satisfactory  as  those  following  division  of  the  "valves" 
with  the  "valve"-clamp. 


CHAPTER  VII 

FECAL  IMPACTION  (COPROSTASIS) 

Fecal  impaction  is  the  accumulation  within  the  bowel 
of  large,  hard,  oval,  or  nodular  fecal  masses,  which  resist  the 
natural  efforts  of  expulsion,  producing  partial  or  complete 
obstruction. 

Enormous  collections  of  clay-like  feces,  inducing  partial 
or  complete  occlusion  of  the  bowel,  may  be  located  in  any  por- 
tion of  the  large  intestine.  Of  these  60  per  cent,  will  be  found 
in  the  rectum,  15  per  cent,  in  the  sigmoid,  10  per  cent,  in  the 
cecum,  and  the  remainder  in  other  portions  of  the  colon.  Im- 
paction occurs  more  frequently  in  women  than  in  men,  and, 
the  older  the  person,  the  more  likely  is  he  to  suffer  from  this 
affection.  No  age  is  exempt,  cases  having  been  recorded  in 
individuals  from  infancy  to  seventy  years  and  more.  This  con- 
dition might  properly  be  distinguished  as  acute  and  chronic- 
acute  when  the  mass  collects  in  a  short  time,  and  chronic  when 
several  weeks  are  required. 

ETIOLOGY   AND   PATHOLOGY 

The  most  frequent  causes  of  coprostasis  are  intestinal  atony, 
paralytic  affections  (locomotor  ataxia),  large  enemata,  mineral 
drugs  showing  a  tendency  to  accumulate,  painful  ailments 
about  the  anus  (fissure),  and  irregular  habits.  In  children  it 
may  result  from  congenital  narrowing  of  the  anus  or  rectum, 
and  in  adults  from  adhesions  following  a  surgical  operation, 
typhoid  fever,  stricture,  carcinoma,  or  tumor  in  a  neighboring 
organ.  The  quantity  and  quality  of  the  food  taken  sometimes 
becomes  an  etiologic  factor  in  impaction.  This  was  thoroughly 
demonstrated  during  the  Irish  famine  in  1846,  when  fecal  ac- 
cumulations were  frequently  caused  by  eating  the  peels  of 
potatoes.  Again,  it  has  been  shown  by  Monro  that  the  people 
of  Scotland  are  frequently  and  similarly  affected  as  a  result  of 
eating  large  quantities  of  coarse  oatmeal.  A  mass  may  have 
for  its  starting-point  a  plum-,  cherry-,  or  gall-  stone,  around 
which  the  feces  collect  like  the  snow  on  a  snow-ball.  Hou- 
ston's "valves" — when  large,  thickened,  and  rigid — may  cause 
(108) 


FECAL  IMPACTION  109 

impaction.  The  author  treated  one  case  where  the  impacted 
mass  rested  immediately  above  the  second  "rectal  valve."  In 
this  case  the  "valve"  projected  into  the  caliber  of  the  bowel 
much  farther  than  is  usual,  was  much  thickened,  highly  in- 
flamed, and  appeared  to  be  the  principal  cause  of  obstruction. 


SYMPTOMS 

The  symptoms  vary,  depending  upon  the  cause,  size,  con- 
sistence, and  location  of  the  impacted  mass.  In  the  beginning 
there  is  constipation ;  later,  constipation  alternating  with  diar- 
rhea; and,  finally,  a  diarrhea  of  the  most  annoying  and  per- 
sistent kind.  Because  liquid  feces  are  being  discharged  around 
or  through  the  fecal  tumor,  the  patient's  real  ailment  is  fre- 
quently not  suspected  by  patient  or  physician.  In  some  cases 
the  movements  have  a  vile  odor.  These  sufferers  are  nervous, 
despondent,  and  restless ;  have  a  muddy  complexion,  disagree- 
able breath,  indigestion,  barking  cough,  morning  vomiting, 
cold  feet,  night-sweats,  thirst,  loss  of  appetite,  dizziness,  some- 
times jaundice,  albuminuria,  seminal  emissions,  varicocele, 
frequent  micturition,  sphincteric  spasm,  "nipple-shaped  anus" 
(Allingham),  and  inflamed  rectal  mucosa.  The  pain  from 
a  fecal  impaction  is  local  and  interrupted  when  it  is  small, 
but  becomes  continuous  and  disseminated  as  it  grows  larger. 
The  mass  produces  a  sensation  of  weight  and  fullness  in 
the  rectum,  frequent  and  prolonged  straining,  and  bearing- 
down  pains  similar  to  those  experienced  during  labor.  Pain 
is  not  confined  to  the  anal  region,  being  frequently  reflected 
to  the  abdomen,  back,  neighboring  organs,  and  down  the  limbs, 
caused  by  pressure  on  the  sciatic  nerves.  In  persons  suffering 
from  impaction  and  fecal  toxemia  the  temperature  is  irregular, 
the  pulse  small  and  weak,  and  respiration  difficult.  They  have 
a  troubled  expression,  are  anemic,  and  occasionally  completely 
collapse  from  exhaustion.  There  may  be  local  or  general  peri- 
tonitis, ulceration,  perforation,  and  fecaloid  vomiting  in  ex- 
treme cases,  due  to  pressure  and  occlusion. 

Fecal  accumulations  may  aggravate  any  pathologic  con- 
ditions present  in  the  rectum,  and  frequently  produce  them 
directly.  The  length  of  time  one  can  live  without  defecation 
has  been  the  subject  of  debate  many  times,  and  still  remains  in 
doubt.     Cases  have  been  recorded  where  complete  occlusion 


110  DISEASES  OF  THE  EECTUM  AND  ANUS 

from  coprostasis  had  existed  for  from  one  week  to  more  than 
six  months  (see  table  of  cases).  The  author  has  treated  sev- 
eral due  to  stricture  in  persons  who  had  not  had  an  evacuation 
in  from  two  weeks  to  two  and  three  months,  and  yet  some  of 
them  were  fairly  comfortable  and  did  not  seem  to  worry. 

Coprostasis  is  the  most  frequent  cause  of  paralytic  ileus; 
the  collective  feces  prevents  the  downward  peristaltic  action, 
interferes  with  proper  nutrition  and  the  nerves  of  the  intes- 
tine, resulting  in  contraction  of  the  bowel  below  the  obstruc- 
tion. The  length  of  contracted  gut  depends  largely  upon  the 
extent  of  the  impaction.  Another  serious  and  frequent  sequel 
of  large  fecal  accumulations  is  dilatation  of  the  colon.  The  bowel 
sometimes  assumes  enormous  proportions.  This  complication 
is  met  with  more  frequently  in  cases  of  recurrent  impaction 
common  to  elderly  persons.  Chronic  constipation  accom- 
panied by  impaction  is  always  an  important  etiologic  factor  in 
chlorosis.  The  anemic  condition  is  brought  about  as  a  result 
of  a  general  fecal  toxemia.  Hence  the  importance  of  teaching 
young  girls  to  be  regular  in  going  to  stool.  This  toxemia 
produces  a  depressing  effect  upon  the  mind,  and  many  of  these 
sufferers  do  not  take  any  interest  in  business,  want  to  remain 
secluded,  and  not  a  few  have  suicidal  tendencies.  In  extreme 
cases  it  has  been  known  to  produce  temporary  mania,  and  in 
young  children  symptoms  simulating  cerebrospinal  meningitis. 
Cases  have  been  recorded  where  auto-infection  from  fecal  ac- 
cumulation has  induced  hyperemia-  and  edema  of  the  brain, 
congestion  of  the  lungs,  and  acute  parenchymatous  degenera- 
tion of  the  heart,  kidneys,  and  lungs  (von  Solder). 


DIAGNOSIS 

Fecal  impaction  is  less  difficult  to  diagnose  than  other 
varieties  of  intestinal  occlusion,  and  yet  the  task  is  not  always 
an  easy  one.  It  is  true  that,  when  a  hard,  large  fecal  mass 
uncovered  by  mucous  membrane  is  situated  in  the  lower  rec- 
tum, a  digital  examination  quickly  reveals  its  nature.  On  the 
other  hand,  when  it  is  partially  covered  by  the  mucosa,  or  when 
located  in  the  sigmoid  flexure  or  colon,  it  is  often  perplexing 
to  make  a  positive  diagnosis.  It  must  be  borne  in  mind  that 
tumors  of  the  intestine,  bladder,  vagina,  uterus,  tubes,  ovaries, 
and  prostate  sometimes  cause  intestinal  occlusion  and  a  long 


FECAL  IMPACTION 


111 


train  of  symptoms  similar  to  those  induced  by  coprostasis. 
When  the  accumulation  is  in  the  rectum  it  is  frequently  mis- 
taken by  the  experienced  finger  for  carcinoma,  because  the 
mass  pushes  the  mucous  membrane  down  in  front  of  it,  giving 
to  the  touch  a  sensation  similar  to  that  of  submucous  cancer. 
The  following  points  should  be  observed  when  differentiating 
between  these  two  conditions : — 


Table  V.     Differential  Diagnosis  Between  Fecal  Impaction  and 
Carcinoma  of  the  Large  Intestine 

carcinoma 
Two  or  more  dense,  rounded  tumors. 


fecal   IMPACTION 

1.  Single,    large,    firm,    and   globular 

in    shape;     or   numerous,    small, 
hard,  and  nodular. 

2.  Usually    not   covered    by    mucous 

membrane. 

3.  Occupies  lumen  of  the  bowel. 

4.  Of    doughy    consistence    and     in- 

dentable. 

5.  Not  attached. 

6.  Movable. 

7.  Occurs  at  any  age. 

8.  No  cachexia. 

9.  Usually  odorless. 

10.  Comes  on  suddenly. 

11.  No    previous    history    of    pain    or 

hemorrhages. 

12.  Not  accompanied  by  discharge  of 

mucus  or  jelly-like  stools. 


Covered     by     mucosa     except     when 
ulcerated. 

Projects  into  the  caliber  of  the  intes- 
tine. 
Hard  and  non-indentable. 

Attached. 

Non-movable  or  slightly  so. 

In  middle  life  and  old  age. 

Cachexia. 

Offensive  odor. 

Slowly. 

Pain  always,  hemorrhages  frequently. 

Free   discharge   of   mucus   and    some- 
times of  jelly-like  evacuations. 


Symptoms  common  to  both  impaction  and  carcinoma  are 
constipation  in  the  beginning,  diarrhea  later,  straining,  frequent 
micturition,  tumor,  and  reflected  pains. 

Fecal  impaction  can  be  differentiated  from  gall-stone, 
enterolith,  and  pancreatic  obstruction  by  the  doughy  feel  and 
the  large  size  of  the  tumor.  When  a  tumor  presents  in  the 
sigmoid  or  colon,  causing  dangerous  symptoms  of  occlusion, 
and  its  nature  is  not  apparent  after  getting  the  history  and 
making  a  thorough  examination  by  means  of  palpation  and 
the  colon-tube,  the  abdomen,  intestine,  or  both  should  be 
opened  without  delay ;  then  an  accurate  diagnosis  can  be  made. 
The  rectum  and  vagina  should  be  examined  in  all  cases  of 
constipation  and  obstipation  to  determine  if  it  is  the  result  of 
an  impaction. 


113  DISEASES  OF  THE  RECTUM  AND  ANUS 

PROGNOSIS 

Comparatively  few  cases  of  uncomplicated  fecal  impaction 
terminate  fatally.  This  is  especially  so  where  there  is  no  or- 
ganic disorder.  When  located  in  the  rectum,  coprostasis  may 
induce  intense  suffering  until  the  mass  is  removed.  Once  the 
bowel  is  empty,  relief  is  instantaneous,  and  the  patient  may 
return  to  his  business  as  usual.  When  the  accumulation  is  the 
result  of  a  stricture,  tumor,  or  adhesions,  the  prognosis  is  not 
so  good;  on  the  contrary,  it  is  extremely  bad  in  most  cases. 
This  is  because  of  the  danger  of  operation  for  temporary  relief 
and  the  tendency  of  the  impaction  to  return  again  and  again 
until  the  pathologic  condition  inducing  the  mechanic  obstruc- 
tion is  removed.  When  the  obstructing  disease  has  been  eradi- 
cated, or  where  a  colotomy  has  been  made  above  it,  and  the 
feces  are  given  a  free  exit,  all  the  elements  of  danger  rapidly 
disappear.     In  those  cases  where  the  fecal  accumulation  is  not 


Fig.  42. — Serviceable  Bed-pan. 

recognized,  and  is  allowed  to  assume  enormous  proportions, 
death  may  at  any  time  ensue,  caused  by  a  rupture  of  the  intes- 
tine or  perforation  and  peritonitis. 

TREATMENT 

The  treatment  in  cases  of  fecal  impaction  is  usually  satis- 
factory, but  must  be  changed  to  suit  the  individual  case.  When 
the  accumulation  is  small,  not  too  dense,  and  is  located  in  the 
lower  rectum,  it  can  always  be  softened  and  evacuated  by  fre- 
quent copious  enemata  of  warm  soap-suds  containing  oil  and 
glycerin.     The  following  is  a  very  satisfactory  combination : — - 

I^  Soap-suds    Oj       473 

Castor-oil    ij         30 

Glycerin     iij        60 

Inject  into  the  rectum  every  two  hours,  to  be  retained  as  long  as  possible. 

If  the  mass  has  been  in  the  rectum  for  some  time ;  is  large, 
round,  or  hard  and  nodular,  more  radical  measures  are  indi- 


FECAL  IMPACTION 


113 


cated,  for  in  such  cases  the  tumor  is  covered  with  a  sHmy  mu- 
cus, and  water  will  not  permeate  it.  Here  it  is  necessary  to 
break  up  the  accumulation  into  small  particles,  and  then  irri- 
gation (Fig.  43)  will  enable  the  patient  to  evacuate  them. 
This    can    be    done    with   the    fingers,    a    spoon-handle,    scoop, 


Fig.   43.— Barger's  Artificial  Defactor  and  Irrigator.      1,   Ready  for  Introduction; 
2,  Showing  Direction  of  Currents  ;  3.  Showing  Component  Parts  of  the  Instrument. 

(Fig.  44),  or  with  Gant's  rectal  forceps.  Where  the  mass 
has  been  present  a  considerable  time,  causing  dangerous  symp- 
toms of  occlusion,  the  sphincter-muscle  should  be  divulsed 
under  general  anesthesia,^  and  the  tumor  delivered  at  once 
whole  or  in  sections.     When  located  in  the  sigmoid  and  colon, 


Fig.  44.— Eectal  Scoop  for  the  Removal  of  Impacted  Feces. 

a  copious  injection  of  the  formula  previously  given  should  be 
thrown  high,  into  the  bowel  by  means  of  the  long  rubber  colon- 
tube.  Occasionally  the  feces  will  be  discharged  in  short  order. 
Again,  the  treatment  must  be  continued  one,  two,  or  three 
days,  and  sometimes  a  week,  before  the  accumulation  will  be 

»  The  muscle  may  be  divided  under  local  anesthetization. 


114 


DISEASES  OF  THE  RECTUM  AND  ANUS 


completely  evacuated.  Massage  is  a  valuable  agent  in  these 
cases,  and,  when  practiced  in  an  intelligent  manner,  fecal  tu- 
mors in  any  part  of  the  intestine  may  be  dislodged,  broken  up, 
and  pushed  downward  until  they  can  be  removed  with  the 
finger  or  washed  out  with  enemata.  Now  and  then  all  pallia- 
tive measures  fail,  and  it  becomes  necessary  to  open  the  abdo- 
men and  make  a  sigmoidotomy  or  colotomy,  and  deliver  the 
mass  whole  when  possible,  and  in  pieces  when  it  cannot  be 
avoided.  Adhesions  should  be  broken  up,  and  the  wounds  in 
both  the  intestine  and  abdomen  should  be  closed  immediately. 


Fig.  45.— Modified  Kelly  Pad. 

When  the  impaction  is  caused  by  a  stricture  or  a  tumor  which 
cannot  be  removed,  a  permanent  artificial  anus  should  be  estab- 
lished. Purgatives  are  always  contra-indicated  in  these  cases, 
because  the  obstruction  is  purely  mechanic. 

The  author  has  treated  during  the  past  few  years  46  cases 
of  fecal  impaction.  (See.  table  of  cases  on  pages  116-119.)  A 
careful  analysis  of  these  cases  develops  the  following  facts: — 

Sex  and  Age. — Of  the  45  cases,  22  were  men  and  23  were 
women.  Their  ages  ranged  from  18  months  to  76  years. 
Twenty-six  were  35  years  or  more,  while  19  were  under  that 
age. 


FECAL  IMPACTION  115 

Location.  —  The  impaction  was  located  in  the  rectum  30 
times ;  sigmoid  and  rectum,  5 ;  sigmoid,  6 ;  colon,  sigmoid, 
and  rectum,  1;  descending  colon,  1;  cecum,  1;  and  transverse 
colon,  1. 

Weight. — The  fecal  accumulations  ranged  in  weight  from 
4  ounces  in  a  child  to  12  pounds  in  an  adult.  The  length  of 
time  these  patients  went  without  stool  varied  from  two  days  to 
three  months. 

The  causes  of  impaction  directly  and  indirectly  were  as 
follows : — 

Stricture,  4 ;  carcinoma,  4 ;  pregnancy,  1 ;  careless  habits, 
5 ;  congenital  malformation  of  the  anus,  1 ;  traumatic  stricture, 
1 ;  paresis,  2 ;  parched  corn,  2 ;  fruit-  and  berry-  stones,  2 ; 
adhesions,  2 ;  fibrous  bands  in  rectum,  1 ;  chronic  constipation, 
2 ;  and  fissure,  2 ;  loss  of  intestinal  tonicity,  5 ;  retroverted 
uterus,  1;  unknown,.  1;  inability  to  evacuate  the  bowel  after 
hemorrhoidal  operation,  1 ;  hypertrophied  sphincter,  1 ;  gall- 
stones, 1 ;  sarcoma,  1 ;  hypertrophied  "rectal  valve,"  1 ;  green 
corn  with  portion  of  cob,  1 ;  h^qDertrophied  levator  ani  muscle, 
1;    disseminated  polypi,  1;    enterolith,  1. 

The  author  has  recorded  these  cases  with  a  view  to  point- 
ing out  the  frequency  of  impaction,  or  coprostasis ;  the  neces- 
sity of  its  prompt  surgical  treatment ;  and,  further,  to  show  the 
varied  affections  and  conditions  which  may  induce  it. 


116 


DISEASES  OF  THE  RECTUM  AND  ANUS 


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CHAPTER  VIII 

AUTO-INFECTION    AND   AUTO=INTOXICATION    FROM 
THE  INTESTINAL  CANAL 

This  topic  is  given  a  distinct  caption,  because  its  impor- 
tance has  been  very  much  underrated,  and  it  is  a  subject  which 
writers  on  rectal  diseases  have  heretofore  ignored.  This  is 
surprising  when  it  is  remembered  that  experiments  have  shown 
that,  in  the  main,  poisons  are  generated  in  the  colon.  Until 
quite  recently  the  fact  that  the  organism  might  be  poisoned  by 
products  generated  within  it,  and  even  be  invaded  by  microbes 
from  the  alimentary  tract,  was  looked  upon  with  much  skep- 
ticism. To-day  nearly  all  physicians  admit  that  such  a  thing  is 
of  common  occurrence.  Recent  investigators  have  shown  that 
various  organs  of  the  body — the  brain,  liver,  lungs,  kidneys, 
etc. — are  frequently  invaded  by  the  bacillus  coli  communis  and 
other  micro-organisms,  and  some  pathologic  condition  induced 
as  a  result  thereof.  They  have  gone  a  step  farther,  and  demon- 
strated that  disease-producing  toxic  substances  are  constantly 
formed  in  health,  independently  of  bacterial  action. 

As  regards  auto-infection  from  the  intestinal  canal,  there 
is  as  yet  little  direct  proof  of  its  existence  or  as  to  the  manner 
in  which  it  occurs.  Many  of  our  best  clinicians  and  investi- 
gators, however,  express  the  belief  that  the  cause  of  many  dis- 
eases, the  pathology  of  which  is  now  obscure,  will  be  explained 
when  we  become  better  acquainted  with  the  part  played  by  the 
contents  of  the  gastro-intestinal  canal. 

From  the  author's  stand-point,  anto-intoxication  from  the 
intestinal  canal  is  that  pathologic  condition  depending  upon 
the  absorption  of  poisons  generated  within  the  alimentary  tract 
as  the  result  of  chemic  processes  or  of  putrefactive  or  fermenta- 
tive changes  of  bacterial  origin. 

Auto-intoxication  may  take  place  from  any  portion  of  the 
intestinal  tract.  It  is  claimed  by  some  that  it  occurs  more  fre- 
quently in  the  small  than  in  the  large  intestine,  for  the  reason 
that  here  an  increased  amount  of  water  is  present  in  the  feces 
which  is  conducive  to  the  solution,  absorption,  and  dissemina- 
(120) 


AUTO-INFECTION  AND  AUTO-INTOXICATION  131 

tion  of  the  poisonous  agents.  On  the  other  hand,  there  are 
many  who  teach  that  the  source  of  auto-mtoxication  is  more 
frequently  the  large  intestine  (especially  the  descending  colon, 
sigmoid,  and  rectum),  because  the  decreased  amount  of  water 
renders  the  feces  more  nearly  solid ;  the  latter  remain  longer 
in  contact  with  the  mucosa ;  and  putrefaction  takes  place  more 
actively,  thus  affording  a  rich  soil  for  the  multiplication  of  sep- 
tic micro-organisms  and  their  products.  These  toxic  elements 
are  taken  up  by  the  circulation,  and  possibly  by  the  lymphatics, 
and  distributed  to  all  parts  of  the  body. 

Before  the  disturbances  which  may  result  from  the  ab- 
sorption of  poisons  created  within  the  intestinal  canal  can 
intelligently  be  studied,  famiharity  with  the  normal  intestinal 
contents  is  absolutely  necessary.  As  it  is  the  intention  of  the 
writer  as  far  as  possible  to  confine  his  study  of  auto-intoxica- 
tion to  the  colon,  only  the  gross  contents  of  the  large  intestine 
will  be  given. 

Grossly  speaking,  the  contents  of  the  colon  is  made  up  of 
refuse  products  of  food,  the  excrementitious  portions  of  the  di- 
gestive fluid,  water,  gases,  and  animal  alkaloids  (leucomains^), 
together  with  myriads  of  micro-organisms  and  their  products 
(ptomains^).  At  present  but  little  is  known  as  regards  the  ac- 
tion of  these  gases  and  alkaloids  in  health  and  disease,  and, 
with  few  exceptions,  the  same  may  be  said  of  the  micro- 
organisms. The  author,  however,  is  firmly  convinced  that  just 
in  proportion  as  physicians  become  familiar  with  the  toxic 
agents  contained  in  the  digestive  fluids  and  excreta  will  they 
understand  many  diseases  which  are  now  called  functional  sim- 
ply because  of  a  lack  of  knowledge  of  their  etiology  and 
pathology.  Bouchard  has  done  more  and  better  work  along 
this  line  than  any  other  man.  This  author  says :  "The  organ- 
ism in  its  normal,  as  in  its  pathologic  state,  is  a  receptacle  and 
a  laboratory  of  poisons.  Some  of  these  are  formed  by  the 
organism  itself,  others  by  microbes,  which  are  either  the 
guests,  the  normal  inhabitants  of  the  intestinal  canal,  or  are 
parasites    at    second-hand    and    disease-producing."' 

He  has  shown  that  the  peptones  of  normal  digestion  con- 
tain poisonous  alkaloids,  and  a  solution  of  them  as  they  appear 
in  the  stomach  as  the  result  of  gastric  and,  lower  down,  of 


*  From  Xei5/cw/ua  =  white  of  egg.    =  From  Trrw/ict  =  corpse. 


123  DISEASES  OF  THE  RECTUM  AND  ANUS 

pancreatic  digestion  will,  when  introduced  into  the  blood  of  an 
animal,  produce  general  disturbances  and  death;  and  also  that 
a  sufficient  amount  of  poison  to  cause  death  in  a  short  time  is 
secreted  by  the  kidneys  when,  from  any  cause,  the  poison  is 
allowed  to  accumulate  or  is  absorbed  as  a  result  of  the  urinary 
tract  becoming  denuded  of  epithelium,  anywhere  from  the 
tubuli  of  the  kidney  to  the  meatus. 

When  renal  suppression  results  in  death,  Bouchard  at- 
tributes it  to  absorption  of  poisons  normally  "secreted,"  and 
not  to  an  accumulation  of  urea ;  and  he  says  that  a  "complexity 
of  phenomena  is  hidden  under  the  name  'uremia.'' " 

Park,  under  the  caption  "Intestinal  Toxemia,"  includes, 
first,  a  condition  of  unusual  or  at  least  undesirable  activity  in 
the  contents  of  the  intestinal  canal  by  which  the  ptomains  of 
putrefaction,  whether  due  to  common  or  specific  forms  of  bac- 
teria, are  produced  in  such  a  manner  or  in  such  quantity  that 
they  are  absorbed  through  the  intestinal  mucosa  and  distrib- 
uted over  the  body,  resulting  in  a  condition  of  intoxication. 
In  this  form  it  is  not  meant  to  imply  that  bacteria  enter  the 
circulation,  but  that  a  more  or  less  profound  toxemia  is  pro- 
duced. Second,  a  form  in  which  the  common  or  uncommon 
bacteria  met  with  in  the  intestinal  canal  pass  into  and  infect 
the  living  tissues  of  the  patient,  producing  local  and  general 
infection  in  addition  to  the  toxemia  above  described.  The  first 
form  occurs  alike  in  medical  and  surgical  cases.  Here,  on  the 
one  hand,  is  a  demonstration  of  how  an  individual  may  become 
intoxicated  from  alkaloidal  poisons  generated  during  digestion, 
and,  on  the  other,  as  a  result  of  the  unusual  activity  of  bacteria 
■ — the  normal  inhabitants  of  the  intestinal  canal — and  their 
ptomains.  As  one  becomes  more  familiar  with  the  almost  in- 
numerable poisons  contained  in  the  intestinal  tract  and  their 
efifect  when  injected  into  the  lower  animals,  he  is  forced  to 
admit  that  mankind  is  constantly  tottering  on  the  brink  of  de- 
struction, and  that  he  need  only  disobey  some  of  Nature's  laws 
to  upset  the  equilibrium  and  fall  a  prey  to  some  of  these  poi- 
sons. Our  Creator,  however,  foresaw  all  dangers,  and  provided 
the  body  abundantly  with  safeguards  with  which  to  destroy  or 
neutralize  the  poisons,  or  to  eliminate  them  as  soon  as  they 
are  formed. 

It  becomes  apparent,  then,  that  for  auto-intoxication  to 
occur  two  thinsfs  are  essential : — • 


AUTO-INFECTION  AND  AUTO-INTOXICATION  123 

1.  There  must  be  local  or  general  impairment  of  phys- 
iologic action. 

2.  That  poisons  are  being  constantly  formed  within  the 
organism  in  health. 

In  all  complex  organisms  every  cell  has  a  duty  to  perform, 
and  the  same  can  be  said  of  those  aggregations  of  cells  which 
are  called  organs.  If  the  function  of  a  single  organ  is  impaired 
or  destroyed,  the  economy  suffers,  and  the  effect  is  in  direct 
proportion  to  the  importance  of  the  work  normally  allotted  to 
that  organ.  Now,  if  from  any  cause,  the  liver,  lungs,  skin, 
kidneys,  or  blood  should  become  deranged  and  fail  to  func- 
tionate, what  is  the  result?  On  the  one  hand,  poisons  that  are 
being  constantly  secreted  are  not  neutralized,  or,  on  the  other, 
are  not  thrown  off,  but  accumulate,  enter  the  circulation  (pos- 
sibly lymphatics),  and  are  distributed  throughout  the  body, 
causing  local  or  systemic  intoxication,  as  the  case  may  be. 
Again,  the  absorption  of  poisons  is  facilitated  by  anything  that 
will  cause  a  lesion  of  the  intestinal  mucosa  or  distend,  press 
upon,  or  weaken  the  walls  of  the  intestine,  such  as  the  accu- 
mulation of  feces,  tumors,  strictures,  ulcerations,  inflamma- 
tions, operations,  etc. 

As  long  as  the  emimctories  work  in  harmony  and  perform 
their  individual  functions,  however,  and  there  is  no  lesion  of 
the  intestinal  mucosa,  all  is  well ;  all  poisons,  no  matter  whether 
they  are  the  product  of  decomposition  or  of  bacterial  action, 
are  rendered  harmless,  for  the  reason  that  they  are  thrown 
into  a  special  reservoir  (the  liver),  where  they  are  destroyed 
or  neutralized  and  afterward  discharged  from  the  body.  Schiff 
ascertained  that  by  injecting  certain  alkaloids  into  a  branch  of 
the  portal  vein  the  proportion  of  poison  in  the  blood  as  it  came 
from  the  liver  was  much  lessened.  The  blood,  however,  con- 
stantly takes  from  the  organs  poisons  as  soon  as  they  are 
formed  and  renders  them  inert,  especially  if  they  are  of  bac- 
terial origin. 

Recent  investigations  have  demonstrated  that  the  serum 
of  arterial  blood  contains  certain  substances  (defensive  pro- 
teids,  alexins^)  which  act  in  one  of  three  ways :  first,  by  kilHng 
the  bacteria  (bactericidal) ;  second,  by  attenuating  or  weak- 
ening the  bacteria;    third,  by  neutralizing  or  destroying  the 


1  From  fiX^lts  =  lielp. 


124  DISEASES  OF  THE  RECTUM  AND  ANUS 

toxins  (antitoxin).  It  has  been  shown  that  the  blood  taken 
from  an  animal  that  has  been  rendered  immune  against  certain 
infectious  diseases  (tetanus,  diphtheria,  etc.),  when  injected  into 
another  animal  or  human  being  renders  such  animal  or  person 
immune  to  that  disease.  Thus  far  investigators  have  been  un- 
able to  isolate  any  one  "defensive  proteid"  that  will  prove 
effective  against  infectious  diseases  in  general,  but  it  is  believed 
that  such  will  be  accomplished  in  the  near  future.  Hankin 
classifies  defensive  proteids  (alexins)  into  two  groups :  1. 
Those  existing  naturally  in  animals  he  calls  sozins}  It  is  a 
noted  fact  that  the  rat  is  immune  to  certain  diseases  to  which 
the  guinea-pig  readily  succumbs.  2.  Those  existing  in  animals 
artificially  made  immune  he  designates  as  phylaxins?  From 
the  above  it  becomes  apparent  that  the  study  of  auto-infection 
is  intimately  connected  with  that  of  immunity. 

It  is  at  times  very  difficult  to  determine  in  cases  of  auto- 
infection  and  intoxication  where  health  leaves  off  and  disease 
begins.  This  is  due,  on  the  one  hand,  to  the  fact  that  these 
poisons  are  physiologic  factors,  and,  on  the  other,  as  soon  as 
the  system  becomes  susceptible  they  become  active  pathologic 
factors. 

The  author  has  neither  the  space  nor  the  inclination  to 
classify  and  point  out  the  pathologic  significance  of  the  various 
poisons  generated  within  the  intestinal  canal.  He  will,  there- 
fore, mention  only  those  manifestations  which  are  due  to  colon 
infection,  are  systemic  in  character,  and  which  are  most  fre- 
quently met  with. 

Perhaps  the  most  frequent  and  immediate  cause  of  auto- 
intoxication is  "constipation,"  more  especially  when  compli- 
cated by  a  fecal  impaction.  In  the  latter  case  there  is  retention 
of  the  feces  for  a  variable  time ;  as  a  natural  sequence,  effete 
matters  accumulate  in  the  bowel  and,  on  retention,  undergo 
chemic  changes;  poisons  of  the  ptomain  and  leucomain  groups 
are  formed  which  are  as  active  as  any  poisons  introduced  from 
without,  as,  for  example,  typhoid  fever  and  cholera,  wherein 
the  specific  bacillus  runs  its  entire  course  in  the  intestine. 

As  a  result  of  the  accumulation  of  poisons  systemic  Intox- 
ication is  induced ;  it  may  or  may  not  run  a  chronic  course, 
depending  upon  the  hygiene  of  the  bowel.     If  nothing  is  done 


1  From  ffu)^€iv  —  save,  keep.     ^  From  (p\j\a^  =  a  guardian,  protector. 


AUTO-INFECTION  AND  AUTO-INTOXICATION  125 

to  prevent  the  continued  formation  and  absorption  of  poison- 
ous products,  their  effects  soon  become  manifest  in  the  cHnic 
pictures  with  which  aU  are  more  or  less  famihar :  anemia.  Pa- 
tients suffering  from  anemia  come  to  the  physician  complaining 
of  headache  and  a  feeling  of  lassitude ;  they  are  impatient  and 
careless  in  attending  to  their  usual  duties ;  they  do  not  care  to 
read  or  talk,  but  are  inclined  to  melancholia,  preferring  to  be 
left  to  themselves ;  they  are  pale,  have  a  greenish-yellow  com- 
plexion and  a  foul  breath.  They  suffer  from  a  depraved  appe- 
tite, indigestion,  palpitation,  dizziness,  neuralgia,  and  a  host 
of  other  symptoms  too  numerous  to  mention.  Too  often  they 
are  treated  for  biliousness,  malaria,  or  grip.  They  change 
from  one  physician  to  another  until  one  is  found  who  makes 
a  correct  diagnosis  and  succeeds  in  removing  the  feces  and 
cures  his  patient  without  any  medicinal  treatment  whatever.^ 
Many  patients  suffering  from  fecal  toxemia  become  so 
profoundly  intoxicated  that  they  present  an  appearance  not 
unlike  that  of  a  person  afflicted  with  a  malignant  growth  in 
an  advanced  stage.  By  way  of  illustration,  a  study  of  the 
phenomena  in  a  case  of  extreme  intestinal  intoxication  will  be 
made  in  order  to  ascertain  its  effect  upon  the  various  systems 
and  skin. 

1.  Circulatory  system.  3.   Skin. 

2.  Respiratory  system.  4.   Nervous  system. 

THE   CIRCULATORY   SYSTEM 

As  a  result  of  auto-intoxication  there  is  a  disturbance  in 
the  circulation :  the  cutaneous  vessels  become  contracted,  thus 
throwing  an  increased  amount  of  blood  into  the  central  organs 
and  interfering  with  the  general  equilibrium.     The  pulse  may 


^  In  a  great  many  of  these  cases  examination  of  the  urine  by  Jaffe's  test  will  lead 
to  a  correct  interpretation  of  the  nature  of  the  disorder  by  the  demonstration  of  the 
presence  of  indican.  This  test  is  performed  as  follows:  To  a  test-tube  one-third  full  of 
urine  add  an  equal  amount  by  bulk  of  strong  hydrochloric  acid;  then,  according  to  the 
size  of  the  test-tube,  add  3  to  6  drops  of  a  Vs-per-cent.  solution  of  potassium  perman- 
ganate and  agitate  the  tube  gently.  If  indican  is  present,  the  fluid  will  become  darker 
in  color.  Should  this  occur,  add  about  a  drachm  of  chloroform  and  shake  vigorously. 
If  the  chloroform  is  now  allowed  to  settle  to  the  bottom  of  the  test-tube,  it  will  be 
seen  to  have  taken  up  the  indican  and  be  colored  a  light  or  dark  blue  or  even  indigo 
tint,  depending  upon  the  amount  of  indican  present.  In  case  of  failure  of  the  first 
examination,  it  is  advisable  to  repeat  the  test  with  varying  amounts  of  the  perman- 
ganate solution;  or  it  may  be  necessary  to  precipitate  the  solids  of  the  urine  with  a 
10-per-cent.  solution  of  sugar  of  lead,  filter,  and  then  treat  with  acid,  permanganate, 
and  chloroform  as  indicated  above. 


126  DISEASES  OF  THE  RECTUM  AND  ANUS 

be  slow  and  full,  or  rapid  and  feeble,  depending  upon  the  de- 
gree of  intoxication  and  its  influence  upon  the  nervous  system 
and  the  muscular  fibers  of  the  heart.  Frequently  the  heart  is 
very  excitable,  and  the  patients  have  fainting  spells.  Some- 
times, instead  of  the  blood  being  retained  in  the  central  organs, 
it  seems  to  remain  in  the  extremities  and  cause  dilatation  of 
the  veins.  Hemorrhoids  are  almost  invariably  present  in  those 
who  suffer  from  chronic  auto-intoxication. 

THE   RESPIRATORY   SYSTEM 

The  effects  of  auto-intoxication  upon  the  respiratory  sys- 
tem are  not  so  numerous  and  profound  as  upon  either  the  cir- 
culatory or  nervous  systems.  Their  effects  are  manifested 
more  quickly,  however,  and  in  a  more  aggravated  form  when 
some  lung  trouble  co-exists ;  and,  vice  versa,  all  lung  diseases 
become  markedly  worse  with  the  advent  of  systemic  intoxica- 
tion, owing  to  deficient  oxygenation  of  the  blood. 

According  to  recent  investigations,  it  would  appear  that 
the  colon  bacillus  plays  an  active  part  in  the  causation  of  some 
forms  of  pneumonia  and  empyema,  but  more  frequently  when 
there  is  a  lesion  of  the  intestinal  mucosa.  When  the  lungs  are 
diseased,  the  gravity  is  in  direct  proportion  to  the  amount  of 
tissue  involved;  when  involvement  is  extensive  and  death  en- 
sues, the  latter  is,  in  great  measure,  due  to  auto-intoxication: 
a  result  of  the  accumulation  and  absorption  of  carbonic  acid 
and  other  poisonous  elements  that  should  have  been  eHminated 
by  the  lungs,  but  chiefly  to  pulmonary  edema  secondary  to 
toxic  action  upon  the  heart. 

THE   SKIN 

The  skin  shows  the  effect  of  intoxication  by  its  pale, 
muddy,  unhealthy  color;  foul-smelling  secretions;  and  in  any 
one  of  many  skin  diseases. 

THE   NERVOUS   SYSTEM 

When  auto-intoxication  exists  to  any  great  degree,  it  be- 
comes manifest  in  the  form  of  some  one  of  the  many  nervous 
disturbances  seen  so  frequently  in  every-day  practice.  One  of 
the  most  common  manifestations  is  a  sensation  of  drowsiness, 
due  to  the  effect  produced  by  absorption  of  one  of  the  intestinal 


AUTO-INFECTION  AND  AUTO-INTOXICATION  127 

gases,  probably  sitlpJiureted  Jiydrogeii,  which  is  known  to  have 
a  soporific  effect.  Though  the  patients  feel  drowsy,  they  are 
poor  sleepers;  they  roll  and  toss  about  the  bed,  are  frequently 
awakened  by  horrible  dreams,  or  find  themselves  wandering 
about  their  rooms.  On  rising  in  the  morning  they  do  not  feel 
refreshed;  on  the  contrary,  they  are  weakened  and  exhausted, 
and  their  clothing  is  often  moistened  by  a  clammy,  unhealthy 
perspiration. 

The  author  believes  that  a  very  large  percentage  of  head- 
aches and  neuralgias,  it  matters  not  where  the  pain  is  located, 
are  due  to  auto-intoxication,  for  he  has  many  times  witnessed 
their  disappearance  after  the  bowels  have  been  completely 
emptied,  without  the  assistance  of  a  single  dose  of  medicine. 
Neurologists  contend  that  a  number  of  functional  nervous  dis- 
orders result  from  fecal  toxemia.  They  have  shown,  from  a 
cHnic  stand-point,  that  some  forms  of  insanity  are  undoubt- 
edly caused  by  auto-intoxication  from  the  intestines,  due  to  the 
absorption  of  gases  or  of  poisons  of  the  ptomain  and  leuco- 
main  groups.  Epileptics  nearly  always  have  fewer  attacks 
when  the  colon  is  kept  clean ;  indeed,  some  authorities  main- 
tain that  not  a  few  cases  can  be  materially  improved  if  proper 
attention  is  paid  to  the  intestinal  canal  with  the  object  of  pre- 
venting accumulation  and  absorption  of  the  manifold  poisons 
generated  therein. 

Thus  far,  in  speaking  of  auto-intoxication,  the  author  has 
incidentally  mentioned  constipation  and  fecal  impaction  as  the 
prime  factors  in  opening  a  way  for  the  production  and  absorp- 
tion of  poisonous  products.  Justice,  however,  would  not  be 
done  to  the  subject  were  he  to  convey  the  impression  that  in- 
fection occurs  only  when  obstinate  constipation  exists.  He  has 
frequently  treated  patients  who  were  unquestionably  suffering 
from  auto-intoxication,  and  nearly  all,  if  not  all,  manifested  the 
phenomena  previously  mentioned.  They  gave  no  histor}^  of 
constipation;  but,  on  the  contrary,  the  intoxication  was  the 
result  of  a  chronic  diarrhea  and  other  causes  which  the  writer 
was  unable  to  determine.^  Park  states :  "There  takes  place 
within  the  intestinal  laboratory  such  a  putrefaction  as  produces 
ptomains  which  are  at  the  same  time  toxic  and  cathartic  in 
their  action,  so  that  the  irritating  material  is  expelled  by  virtue 


1  Here,  also,  examination  of  the  urine  by  Jaffe's  test  will  render  great  assistance 
'n  diagnosis  (see  foot-note  on  page  125). 


128  DISEASES  OF  THE  RECTUM  AND  ANUS 

of  the  very  poisons  it  has  produced ;  and  it  furthermore  often 
happens  that  the  exhibition  of  a  vigorous  cathartic — for  in- 
stance, one  of  the  mercurials — will  so  admirably  clean  out  the 
entire  intestinal  canal  that  not  merely  is  the  entire  action  pre- 
vented or  checked  when  present,  but  that  a  most  happy  effect 
is  exerted  upon  septic  disturbances  commencing  elsewhere." 

The  author  has  personally  treated  not  a  few  patients  suf- 
fering from  chronic  proctitis  and  ulceration  of  the  colon  or 
rectum  where  the  ulcers  were  small  and  not  unhealthy  looking, 
who  also  suffered  from  systemic  intoxication.  They  were  very 
much  emaciated,  extremely  nervous,  of  sallow  complexion,  in- 
clined to  be  melancholic ;  in  fact,  they  manifested  all  the  symp- 
toms which  usually  accompany  auto-intoxication.  Diarrhea  is 
ever  a  prominent  symptom  of  ulceration,  and  it  complicates 
matters  by  distributing  the  poisonous  elements  in  the  feces  to 
any  exposed  point  of  the  mucosa,  thereby  facihtating  their  en- 
trance into  the  circulation.  Not  all  cases  of  ulceration  of  the 
rectum  and  colon,  however,  are  complicated  with  systemic  in- 
toxication. Many  times  the  poisons  are  rendered  inert  or  are 
eliminated  before  much  harm  can  result.  Perhaps  the  most 
typic  cases  of  auto-intoxication  from  the  intestinal  canal  are  to 
be  found  in  patients  suffering  from  stricture  of  the  rectum  and 
colon. 

In  these  cases  are  found  the  two  conditions  which  par 
excellence  favor  auto-intoxication :  (a)  fecal  impaction  above 
the  point  of  constriction,  and  (h)  frequent  liquid  stools  induced 
by  a  reflex  peristalsis.  The  former  prepares  the  field  by  causing 
ulceration  of  the  walls  of  the  bowel,  offering  a  good  culture- 
medium  for  the  micro-organisms  and  favoring  putrefaction  and 
fermentation.  The  latter,  being  liquid,  take  up  the  poisons  and 
distribute  them.  As  a  result,  more  poisons  are  generated  and 
absorbed  than  Nature  can  take  care  of;  the  system,  therefore, 
becomes  saturated.  As  has  already  been  stated,  the  sufferers 
acquire  an  aspect  almost  as  bad  as  that  observed  in  individuals 
suffering  from  a  malignant  growth.  In  fact,  any  disturbance 
of  the  rectum  and  the  colon  that  will  cause  a  diarrhea  or  con- 
stipation predisposes  the  individual  to  auto-intoxication  and  its 
many  evils. 

In  the  preceding  pages  attention  has  been  called  to  some 
general  manifestations  which  the  author  believes  are  caused  by 
the  absorption  of  septic  material  from  the  intestinal  canal. 


AUTO-INFECTION  AND  AUTO-INTOXICATION  129 

BACILLUS   COLI   COMMUNIS 

Attention  is  now  directed  to  the  study  of  a  number  of 
diseases  in  and  around  the  rectum  and  other  organs,  which,  if 
not  directly  caused  by  intestinal  bacteria,  are  certainly  aggra- 
vated and  perpetuated  by  them.  The  micro-organism  of  intes- 
tinal origin  most  frequently  associated  with  disturbances  in 
neighboring  and  distant  parts  is  the  bacillus  coli  communis.  This 
microbe  seems  to  be  the  chief  disturber,  and  has  been  found  in 
nearly  all  the  organs  of  the  body  and  under  circumstances  that 
have  led  investigators  to  conclude  that  it  unquestionably  pos- 
sesses decided  pyogenic  properties.  Many  other  germs  of 
known  pathogenesis  have  been  proven  to  be  identic  with  this 
bacillus;  and  at  present  it  is  considered  identic  with  the  fol- 
lowing organisms :  The  bacillus  Neapolitanus,  Breiger's  feces 
bacillus,  Passet's  bacillus  pyogenes  fcetidus,  the  urinary  pyogenic 
bacterium  (Clado  and  Albarran)  which  Morelle  and  Krogius 
considered  identic  with  the  bacillus  lactis  aerogenes,  the  uroba- 
cillus  septicns,  and  the  septic  bacterium  discovered  by  Bouchard. 
Familiarity  with  this  bacillus  is  of  such  importance  to  both 
physician  and  surgeon  that  it  will  be  discussed  in  detail. 

The  following  description  of  the  appearance,  growth,  prop- 
erties, pathogenesis,  etc.,  of  the  bacillus  coli  communis  is  taken 
from  Ball^  because  of  its  brevity : — 

"Bacillus  Coli  Communis  (Escherich). — Found  in  the  human  feces, 
intestinal  canal  of  most  animals,  in  pus,  and  Avater. 

"Form. — Short  rods  with  very  slow  movement;  often  associated  in  little 
masses,  resembling  the  typhoid  germ. 

"Properties. — Does  not  liquefy  gelatin;  causes  fermentation  in  saccharin 
solutions  in  the  absence  of  oxygen;  produces  acid  fermentation  in  milk. 

"Groivtli. — On  potato  a  thick,  moist,  yellow-colored  growth.  Very  soon 
after  inoculation  on  gelatin  a  growth  similar  to  typhoid.  It  can  also  develop 
in  carbolized  gelatin,  anti  withstands  a  temperature  of  45°  C.  without  its  growth 
being  destroyed. 

"Pathogenesis. — Inoculated  into  rabbits  or  guinea-pigs,  death  follows 
in  from  one  to  three  days,  the  symptoms  being  those  of  diarrhea  and  coma; 
after  death  tumefactions  of  Peyer's  patches  and  other  parts  of  the  intestine; 
perforations  into  the  peritoneal  cavity,  the  blood  containing  a  large  number  of 
germs. 

"Staining. — Ordinary  stains;   does  not  take  Gram. 

"Site. — The  bacillus  has  been  found  very  constant  in  acute  peritonitis  and 
in  cholera  nostras.    Its  presence  in  water  would  indicate  fecal  contamination. 


1  "Essentials  of  Bacteriology,"  M.  V.  Ball.     Second  edition. 


130  DISEASES  OF  THE  EECTUM  AND  ANUS 

"The  growth  on  potato,  the  effect  on  animals,  and  its  action  toward  milk 
are  points  of  diflference  from  the  typhoid  bacillus." 

The  author  has  made  no  personal  experiments  to  deter- 
mine the  pathogenic  and  pyogenic  properties  of  the  bacillus 
coli  communis.  For  this  reason  the  experiments  and  arguments 
of  those  who  have  made  a  special  study  of  this  microbe  will  be 
quoted  in  extenso  in  order  to  show  the  part  played  by  this 
normal  inhabitant  of  the  intestinal  canal  in  causing  disease 
under  varying  circumstances. 

Roswell  Park,  in  speaking  of  the  bacillus  coli  communis^ 
relates  the  following  history  concerning  it:  "It  was  first  de- 
scribed in  1885  by  Escherich,  and  was  first  regarded  as  a 
saprophyte  and  intestinal  parasite.  In  1887  Hueppe  found  it 
in  the  stools  of  a  patient  suffering  from  cholerine.  Its  positive 
pathogenic  properties  were  first  made  known  by  Lauelle  in 
1889,  then  by  Tavel,  also  by  Rodet  and  Roux,  who  fully  estab- 
Hshed  its  pyogenic  properties."  He  further  says  that  the  colon 
bacillus  is  a  short,  rod-shaped  organism  which  is  motile  in 
hanging  drop,  its  motihty  consisting  of  a  sort  of  oscillation, 
and  sometimes  with  a  rapid  translation.  Its  possession  of 
flagella  is  disputed;  at  most,  it  does  not  have  more  than  three 
of  them,  while  the  typhoid  bacillus  possesses  from  eight  to 
twelve  or  more.  It  seems  to  enjoy  a  sort  of  commensahsm, 
possibly  even  a  symbiosis.  It  practically  never  exists  alone  in 
the  healthy  intestinal  canal,  but  under  certain  conditions  it  is 
found  alone  in  other  parts  of  the  body.  Ordinarily  it  is  not 
virulent;  under  certain  circumstances,  however,  its  virulence 
varies  within  wide  limits,  as  is  the  case  when  obtained  from 
cholera  nostras,  and  on  inoculation  it  causes  death  from  acute 
septic  infection  within  twenty-four  hours.  When  derived  from 
intra-abdominal  abscesses,  it  is  only  slightly  infectious.  This 
organism  therefore  may  exist,  first,  as  an  exceedingly  active 
agent,  producing  acute  general  infection ;  second,  as  a  com- 
mon pyogenic  organism,  producing  local  abscess. 

Pathogenic  Action. — To  show  the  pathogenic  action  of  the 
colon  bacillus,  the  writer  quotes  from  a  paper  by  Dr.  William. 
H.  Welch,  of  Baltimore,  read  before  the  Second  Congress  of 
American  Physicians  and  Surgeons.     He  said : — 

"Tavel's  observations  of  the  colon  bacillus  in  connection 
with  wound-infection  were  followed  by  a  few  isolated  observa- 
tions of  this  organism,  either  in  the  unchanged  organs  of  the 


AUTO-INFECTION  AND  AUTO-INTOXICATION  131 

ho6y  or  in  suppurations,  until  recently.  A.  Frankel  reports  its 
presence  in  9  out  of  31  cases  of  peritonitis.  I  first  came  across 
this  bacillus  in  the  organs  of  the  body  in  1889-90,  in  a  case  of 
multiple  fat-necrosis  with  pancreatitis,  which  I  reported  to  the 
Association  of  Physicians.  As  in  this  case  diphtheritic  colitis 
existed,  it  seems  probable  that  the  lesions  of  the  intestine 
opened  the  way  for  the  entrance  into  the  circulation  of  this  in- 
habitant of  the  healthy  intestinal  canal.  This  view  subsequent 
experience  has  confirmed. 

"I  have  almost  uniformly  failed  to  find  it  outside  of  the 
intestinal  wound  when  no  demonstrated  lesion  of  the  mucous 
membrane  existed.  I  am,  therefore,  prepared  to  say  that  this 
bacillus  is  an  extremely  infrequent  invader  in  intestinal  diseases. 
Moreover,  the  colon  bacillus  does  not  invade  the  blood  and 
organs  in  the  process  of  post-mortem  decomposition. 

"The  cases  in  which  we  have  found  the  colon  bacillus  un- 
der circumstances  pointing  to  its  pathogenic  action  have  been 
as  follows:  Perforative  peritonitis,  4  cases;  peritonitis  sec- 
ondary to  intestinal  disease  without  perforation,  2  cases;  cir- 
cumscribed abscess,  3  cases ;   and  laparotomy  wounds,  6  cases, 

'Tts  presence  several  times  in  pure  culture,  in  laparotomy 
w^ounds  treated  aseptically,  although  apparently  not  a  source 
of  serious  trouble,  was  not  a  matter  of  indifference.  It  was 
generally  accompanied  with  moderate  fever,  and  with  a  thin, 
brownish,  slightly-purulent  discharge,  of  somewhat  offensive, 
but  not  putrefactive,  odor.  * 

"The  smooth  and  rapid  healing  of  the  wound  was  inter- 
fered with.  In  some  of  the  cases  there  was  evidence  of  intes- 
tinal disorder;  in  others  this  was  not  apparent,  and  infection 
from  without  could  not  be  excluded. 

"For  the  purpose  of  the  present  discussion,  perhaps  the 
chief  interest  of  our  observations  concerning  the  colon  bacillus 
is  that  they  furnish  illustration  of  the  predisposition  to  infec- 
tion afforded  by  intestinal  lesions,  and  also  give  example  of  the 
much-disputed  mtto-infection." 

Park,  at  the  same  meeting,  spoke  of  enterosepsis  produced 
by  this  bacillus  in  cases  of  abdominal  surgery.  He  said  that, 
under  some  circumstances,  it  either  escapes  or  is  carried  be- 
yond its  normal  limits,  and,  entering  the  portal  circulation, 
perhaps  the  lymphatics  as  well,  appears  to  set  up  septic  dis- 
turbances w^hich  are  typified  by  the  production  of  septic  peri- 


132  DISEASES  OF  THE  EECTUM  AND  ANUS 

tonitis,  and  possibly  other  forms  of  septicemia  in  which  the 
peritoneum  does  not  primarily  figure :  a  condition  which  Drs. 
Welch  and  Councilman  call  colon  infection. 

The  author  will  not  attempt  to  do  more  than  mention  a 
few  of  the  diseases  in  which  the  colon  bacillus  appears  to  be 
the  most  active  agent.  It  has  been  known  to  manifest  its  pres- 
ence in  the  following  conditions : — 

1.  Infectious  diarrhea. 

2.  Empyema  (following  enteritis). 

3.  Broncho-pneumonia. 

4.  Endocarditis. 

5.  Cystitis. 

6.  Nephritis  and  pyelonephritis  (surgical  kidney). 
Y.  Disorders  of  the  liver  (icterus). 

8.  Appendicitis. 

9.  Periappendical  abscess. 

10.  Perforative  peritonitis  (also  in  cases  of  lesions  of  the 
intestine  without  a  perforation). 

11.  Laparotomy  wounds. 

12.  Strangulated  hernia  (in  fluid  of). 

13.  Perirectal  abscess,  etc. 

14.  Cholecystitis. 

A  casual  glance  at  the  above  diseases  in  which  this  germ 
is  knoivn  to  be  an  etiologic  factor  is  sufficient  proof  of  its 
pathogenic  and  pyogenic  properties.  Until  quite  recently  it 
was  supposed  that  this  germ  did  not  enter  the  circulation  and 
produce  disease  in  distant  parts  unless  there  was  a  lesion  of 
the  intestinal  mucosa.  To-day  such  excellent  authorities  as 
Welch,  Park,  Councilman,  and  others  teach  that  the  bacillus 
coll  communis  may  enter  the  circulation  and  produce  distm-b- 
ances  independent  of  any  intestinal  lesion.  It  is  quite  easy  to 
understand  the  route  by  which  it  reaches  and  infects  the 
genito-urinary  tract  and  liver.  It  is  not  infrequently  intro- 
duced into  the  urethra  and  bladder  by  means  of  an  unclean 
sound  or  other  instrument,  and  from  thence  to  the  kidneys 
through  the  ureters.  As  to  reaching  the  liver,  this  normal 
inhabitant  of  the  intestine  very  easily  finds  its  way  up  the  in- 
testine and  through  the  common  bile-duct  to  the  organ,  where 
it  causes  infection.  It  is  remarkable  that  biliary  infection  is 
so  rarely  encountered. 

That  portion  of  the  subject  which  more  especially  con- 


AUTO-IXFECTION  AND  AUTOINTOXICATION  133 

cerns  those  who  are  interested  in  rectal  and  anal  diseases  will 
now  be  considered.  For  a  considerable  time  past  the  author 
has  inclined  to  the  belief  that  the  colon  bacilli,  either  alone  or 
associated  with  some  other  bacteria,  frequently  cause  peri- 
proctitis and  ischio-rectal  abscess,  and  possibly  proctitis.  If 
allowed  to  run  an  uninterrupted  course  proctitis  often  results 
in  abscess,  fistula,  or  a  stricture,  as  the  result  of  diminution  of 
the  lumen  of  the  bowel  by  inflammatory  deposits  or  vicious 
cicatrization  following  ulceration.  If  future  investigations 
prove  these  intestinal  bacteria  to  be  the  exciters  of  the  inflam- 
mation and  incidentally  of  the  sequels,  they  will,  in  all  prob- 
ability, also  furnish  an  explanation  of  the  cause  of  a  large  per- 
centage of  strictures  which,  when  they  cannot  be  assigned  to 
traumatism,  syphilis,  tuberculosis,  dysentery,  etc.,  are  at  pres- 
ent classified  as  due  to  "unknown  causes." 

In  order  to  obtain  the  latest  information  relative  to  this 
important  subject.  Dr.  Roswell  Park,  of  Buffalo,  and  Dr.  Will- 
iam H.  Welch,  of  Baltimore,  were  asked  for  opinions  as  to 
auto-infection,  the  part  played  therem  by  the  colon  bacillus, 
and  what  role,  if  any,  this  bacillus  assumes  in  the  causation  or 
continuance  of  certain  local  diseases  of  the  colon  and  rectum, 
such  as  proctitis,  abscess,  etc.  The  author  takes  this  opportu- 
nity to  publicly  thank  both  Dr.  Welch  and  Dr.  Park  for  the 
many  valuable  suggestions  contained  in  their  replies,  and 
deems  it  best  to  record  their  answers  verbatim. 

De.  Paek's  Eeply 

Buffalo,  June  21,  1894. 
Dk.  S.  G.  Gant,  Ninth  and  Grand  Aveiiue,  Kansas  City,  Mo. 

Dear  Doctor:  In  reply  to  your  favor  of  the  16th  I  would  say  that  I 
send  herewith  one  or  two  jDapers  bearing  on  the  subject  of  which  you  write, 
and  that  I  must  refer  you  also  to  a  book  published  by  me  two  years  ago, 
entitled  "Miitter  Lectures  on  Surgical  Pathology,"  in  which  I  have  devoted 
some  little  space  to  the  matter  of  intestinal  toxemia.  This  book  was  issued 
by  J.  H.  Chambers  &  Co.,  of  St.  Louis.  I  regret  that  I  have  not  a  copy  at 
hand  which  I  could  send  you.  The  subject  is  to  me  one  of  very  great  impor- 
tance, and  I  am  glad  that  you  are  going  to  devote  some  attention  to  it  in  your 
forthcoming  work. 

I  have  no  doubt  that  the  colon  bacillus  does  play  an  important  role  in 
diseases  of  the  rectum  and  colon,  but  it  is  difficult  to  say  under  just  what 
circumstances.  In  the  light  of  the  most  recent  investigations  it  occurs  to  me 
that  perhaps  a  little  too  much  importance  has  been  assigned  to  it  as  the  sole 
factor  in  these  troubles,  and  that  many  cases  in  which  it  is  prominent  are  due 


134  DISEASES  OF  THE  RECTUM  AND  ANUS 

to  really  a  mixed  infection  by  which  the  virulence  of  two  or  three  different 
forms  is  vei-y  much  increased.  It  is,  however,  considered  to  be  identical  with 
the  bacillus  pyogenes  fcetidus,  which  is  a  common  organism  in  many  cases  of 
perirectal  abscess.  I  have  found  them  in  various  abscesses  around  the  colon, 
higher  up,  and  even  on  the  right  side,  and  of  these  I  can  say  that  at  the  time 
of  opening,  at  least,  the  pus  seemed  to  be  pure  culture  of  this  organism.  This 
ia  not  true,  however,  of  all  cases,  by  any  means,  and  it  may  be  that  in  most 
of  them  some  other  organism  has  been  present  and  has  died  out,  for  many  of 
them  are  of  considerable  standing. 

I  have  also,  as  reported  in  one  of  my  papers,  found  pure  cultures  of 
colon  bacillus  in  most  cases  of  periappendical  abscesses  which  I  have  thus 
investigated,  and  I  do  think  that  it  is  a  most  active  factor  in  this  kind  of 
disturbance.  I  think  the  circumstances  which  most  co-operate  to  make  this 
organism  virulent  are  the  presence  of  certain  putrefactive  organisms  combined 
with  habitual  constipation.  Mere  ulceration  or  abrasion  of  the  mucosa,  by 
itself,  I  think  may  predispose  to  virulence  of  effect  of  the  organism,  but  such 
ulceration  is  not  very  likely  to  be  brought  about  by  the  said  causes  which 
tend  to  make  the  organism  more  virulent. 

In  reply  to  your  third  query  as  to  whether  the  bacillus  can  enter  the 
circulation  through  sound  membranes,  there  is  every  reason  to  think  it  can. 
Numerous  investigators  have  found  it  under  many  circumstances,  and  I  con- 
sider it  settled  that  this  is  possible. 

In  reply  to  the  fourth  question,  I  think  it  is  the  case  that  the  bacillus 
multiplies  more  abundantly  when  the  stools  are  liquid,  because  such  a  condi- 
.  tion  furnishes  a  more  suitable  culture-medium  for  it,  with  a  more  lively  dis- 
tribution; but  I  really  cannot  tell  which  of  the  two  conditions,  diarrhea  or 
constipation,  is  more  likely  to  cause  auto-infection. 

In  a  general  way  I  think  that  much  depends  upon  the  condition  of  the 
other  eliminatory  portions  of  the  system.  For  instance,  if  there  be  oliguria, 
I  think  extra  work  is  thrown  upon  the  alimentary  canal;  and  when  to  this 
is  added  the  sluggishness  of  the  skin  in  many  anemic  and  debilitated  indi- 
viduals, I  think  everything  conspires  to  make  the  condition  of  the  intestinal 
canal  Avorse  and  more  active.  I  think,  also,  much  depends  upon  dilatation  of 
the  stomach,  which  is  often  present,  in  at  least  more  or  less  degree,  and  upon 
the  perfection  of  disposition  of  the  stomach-contents.  The  presence  of  lactic 
and  of  fatty  acids  has  much  to  do,  I  am  sure,  with  the  trouble,  and  yet  I 
certainly  cannot  tell  you  just  how,  nor  do  I  know  of  anyone  who  can. 

Eeasoning  from  the  other  direction,  I  am  quite  sure  one  gets  valuable 
suggestions,  if  not  exact  knowledge,  from  the  fact  that  the  very  best  treatment, 
in  my  estimation,  for  operation,  and  especially  for  abdominal  operations,  con- 
sists largely  of  carefully  purging  for  several  days  before  the  operation  itself. 
This  is  with  reference  not  only  to  the  colon  bacillus,  but  to  all  the  organisms 
which  inhabit  the  intestinal  canal.  If  one  remembers  that  the  colon  bacillus 
belongs  primarily  in  the  intestines,  and  that  it  is  identical  with  other  forms 
discovered  by  various  observers,  to  which  different  roles  have  been  assigned, 
one  will  get  a  better  idea  of  the  possibilities  and  properties  of  this  organism. 
I  have  no  doubt  there  are  pure  types  of  colon  infection  which  produce  peri- 
tonitis (this  is  particularly  the  case  with  appendical  trouble),  but,  as  every 
surgeon  knows,  these  cases  are  not  invariably  fatal,  and  many  observations 


•       AUTO-INFECTION  AND  AUTO-INTOXICATION  135 

conspire  to  prove  the  benefit  of  clearing  out  the  alimentary  canal  when  this 
condition  is  in  its  incipiency  or  perhaps  merely  threatening. 

I  shall  await  the  appearance  of  your  forthcoming  book  with  no  little 
interest,  and  shall  be  very  glad  if  in  the  slightest  degree  I  have  helped  to  call 
attention  to  this  very  important  subject. 

Very  sincerely  yours, 
[Signed]  Roswell  Pabk. 

(Die.  to  steno.) 

De.  Welch's  Eeplt 

935  St.  Paul  St.,  Baltimore,  June  26,  1894. 
S.  G.  Gant,  Esq.,  M.D.,  Kansas  City,  Mo. 

Dear  Doctor:  My  first  observation  of  invasion  of  internal  organs  of  the 
body  by  the  bacillus  coli  communis — and,  I  believe,  the  first  on  record — was 
reported  by  me  to  the  Association  of  American  Physicians  in  1889,  I  think  (1 
have  not  the  reference  at  hand).  This  was  in  a  case  of  multiple  fat-necrosis 
associated  with  diphtheritic  colitis.  In  the  article  referred  to  by  you  in  the 
Medical  News  I  gave  the  conclusion  reached  up  to  that  time.  I  have  no  doubt 
that  the  colon  'bacillus  is  a  frequent  invader  of  the  circulation  and  internal 
organs,  particularly  the  lungs,  kidney,  and  liver,  in  cases  with  lesions  of  the 
intestinal  mucosa,  and  sometimes  without  such  lesion  being  demonstrable. 
In  the  great  majority  of  these  cases,  in  which  we  are  able  to  demonstrate  by 
culture  at  autopsy  the  presence  of  the  colon  bacillus  outside  of  the  intestinal 
tract,  there  is  no  evidence  that  such  invasion  has  produced  any  damage.  Micro- 
scopic sections  show  colon  bacilli  often  abundantly  in  the  blood-vessels  of  the 
kidney,  and  often  in  parts  without  evidence  of  lesion  of  the  surrounding  parts. 
These  facts,  it  seems  to  me,  justify  skepticism  about  referring  to  the  colon 
Mcillus  as  of  great  importance,  as  many  nowadays  do,  even  when  it  is  present 
in  inflammatory  areas.  One  must  consider  whether,  in  such  cases  with  actual 
lesion,  it  may  not  be  a  secondary  invader  in  parts  primarily  diseased  through 
some  other  agency,  including  other  micro-organisms.  I  have,  for  example, 
found  the  colon  bacillus  in  tuberculous  pyelitis  and  in  gonorrheal  pyelitis.  The 
primary  micro-organisms  may  have  died  out  and  the  colon  bacillus,  which  is 
a  resistant  micro-organism,  may  survive  alone  and  keep  up  the  inflammation. 
Still,  there  are,  of  course,  observations  which  leave  little  doubt  that  the  colon 
bacillus  may  exert  definite  pathogenic  action.  I  contend,  however,  that  not  a 
few  cases  recorded  in  which  disease  has  been  attributed  to  the  colon  bacillus 
will  not  stand  critical  scrutiny  in  the  light  of  all  the  facts  which  are  now 
known.  In  my  paper  on  "Conditions  Underlying  the  Infection  of  Wounds" 
(Transactions  of  the  Congress  of  American  Physicians  and  Surgeons,  volume  ii) 
I  express  myself  with  candor  as  to  the  pathogenic  role  of  the  colon  bacillus. 
I  am  very  skeptical  about  the  prevalent  view  that  the  colon  bacillus  is  the 
cause  of  appendicitis.  Being  a  constant  inhabitant  of  the  intestine,  it,  of  course, 
is  present  in  the  diseased  as  well  as  the  normal  appendix,  but  in  the  former 
case,  in  my  experience,  usually  in  association  with  unquestioned  pyogenic  bac- 
teria. The  same  has  been  my  experience  in  perforative  peritonitis,  contrary  to 
that  of  some  French  and  Italian  observers.    The  colon  bacillus  is  so  widely  prev- 


136  DISEASES  OF  THE  RECTUM  AND  ANUS 

alent,  it  is  so  easy  to  cultivate  on  all  media  and  at  all  temperatures,  that  I 
cannot  help  suspecting  that  often  other  bacteria  were  overlooked. 

As  regards  the  relation  of  the  colon  Mcillus  to  proctitis  and  periproctitis, 
I  doubt  very  much  whether  it  is  capable  of  causing  either  of  these  diseases  in 
healthy  tissue.  It  is  certainly  found  with  gi-eat  regularity  in  perirectal  ab- 
scesses, usually,  I  think,  in  combination  with  other  bacteria  of  proven  pyogenic 
power,  but  sometimes  in  pure  culture.  In  the  latter  case,  however,  I  should 
suspect  previous  disease  of  the  part  from  some  other  agent,  although,  given 
this  primary  lesion,  the  colon  bacillus  may  be  a  factor  of  importance  in  pro- 
ducing and  confirming  the  suppuration. 

As  regards  the  general  subject  of  auto-infection  from  the  intestinal  canal, 
of  course,  although  the  colon  bacillns  is  the  most  common  invader,  other  bac- 
teria may  likewise  enter  through  this  portal,  notably  the  pyogenic  micrococci. 
Definite  lesions  of  the  intestinal  mucosa  here,  too,  are  important  predisposing 
factors,  as  is  illustrated  in  some  cases  of  secondary  infection  in  dysentery, 
typhoid  fever,  etc.  As  regards  the  predisposing  influence  to  infection,  which 
may  be  exerted  by  absorption  of  toxic  substances,  products  of  decomposition, 
etc.,  from  the  intestinal  canal,  it  seems  to  me  that  we  have  very  little  definite 
information,  although  plenty  of  speculation. 

The  question  of  invasion  of  the  colon  bacillus  and  its  pathogenic  signifi- 
cance were  considered  by  me  in  the  "Middleton  Goldsmith  Lecture"'  before  the 
Pathological  Society  of  New  York  at  the  end  of  last. April.  The  lecture  has 
not  been  published,  but  will  appear  in  the  New  York  Medical  Journal  in  the 
course  of  a  couple  of  months.  I  must  refer  you  to  that  for  a  fuller  statement 
of  my  views  on  this  subject. 

Hoping  that  I  may  have  touched  upon  some  of  the  points  on  which  you 
desired  my  views,  I  am. 

Very   truly   yours, 
[Signed]  William  H.  Welch. 


TREATMENT 

The  author  will  not  attempt  a  detailed  discussion  of  the 
many  remedies  that  have  been  suggested  for  the  prevention 
and  relief  of  auto-intoxication  of  intestinal  origin,  but  will 
mention  only  the  more  important  measures  that  have  been 
adopted. 

The  treatment  should  be,  in  a  large  measure,  prophylactic. 
Every  effort  should  be  made  to  keep  the  system  in  perfect 
order  and  the  equilibrium  maintained ;  so  long  as  this  is  ac- 
complished, Nature  is  capable  of  defending  herself  against  any 
and  all  toxic  substances  generated  within  the  body.  Any  dis- 
ease or  symptom  of  a  disease  that  predisposes  a  patient  to 
auto-intoxication  from  poisons  normally  generated  within  the 
body  must  be  eradicated  at  once.     There  are  three  essential 


AUTO-INFECTION  AND  AUTO-INTOXICATION  137 

features  that  must  be  constantly  borne  in  mind  in  the  treat- 
ment of  auto-intoxication : — 

1.  Any  condition  which  predisposes  the  patient  to  seh'- 
intoxication  must  be  remedied. 

2.  Every  possible  means  should  be  employed  to  prevent 
the  abnormal  production  and  absorption  of  poisons  within  the 
intestinal  canal. 

3.  Nature  should  be  assisted  in  every  way  to  neutralize 
and  eliminate  poisons  already  absorbed. 

For  accomplishment  of  the  first  any  condition  that  will 
erode  or  weaken  the  mucosa  in  any  way  must  be  corrected, 
because  it  prepares  a  portal  for  the  entrance  into  the  circula- 
tion of  toxic  substances  from  the  intestine.  Hence,  irritative 
discharges  of  all  kinds  must  be  corrected,  ulcers  and  fissures 
must  be  healed,  and  hemorrhoids,  polyps,  and  other  growths 
removed.  In. fact,  any  local  disease  of  the  rectum  and  colon 
must  be  eradicated,  otherwise  all  efforts  directed  toward  the 
prevention  and  relief  of  auto-intoxication  will  be  of  no  avail. 

There  are  some  cases  in  which  no  local  cause  can  be  ascer- 
tr.ined.  Even  in  these  cases  the  hygienic  condition  of  the 
bowel  should  be  improved,  so  far  as  possible,  by  frequent 
flushings  of  the  colon  with  sterile  water  and  antiseptic  solu- 
tions. In  such  instances  a  cause  must  then  be  sought  else- 
where, and  in  all  probability  it  will  be  found  to  be  either 
diarrhea  or  constipation  and  fecal  impaction.  When  due  to 
either,'  the  fine  of  treatment  previously  laid  down  in  the  chap- 
ters devoted  to  these  subjects  should  be  carried  out.  When- 
ever an  irritant  is  present  within  the  intestinal  canal  promoting 
auto-intoxication,  the  safest  plan  is  to  give  a  vigorous  cathartic, 
a  mercurial  if  preferred,  which  will  cause  its  expulsion.  Laxa- 
tive tonic  treatment  must  then  be  instituted  and  continued  for 
a  long  or  a  short  period,  according  to  the  extent  and  chro- 
nicity  of  the  infection.  Very  often  poisonous  substances  can  be 
eliminated  from  the  system  by  the  constant  and  liberal  use  of 
reputable  mineral  waters  known  to  have  a  cathartic  action. 
Sometimes  it  will  be  necessary  to  administer,  in  addition,  a  pill 
composed  of  aloin,  strychnine,  and  belladonna,  or  one  com- 
posed of  the  lactate  of  iron,  extract  of  nux  vomica,  and  puri- 
fied aloes,  given  three  times  a  day.  Perhaps  the  most  striking 
example  of  the  importance  of  cleansing  the  intestinal  canal  is 
to  be  seen  after  abdominal  operations.    All  have  observed  the 


138  DISEASES  OF  THE  RECTUM  AND  ANUS 

temperature  of  a  patient  suddenly  rise  two  or  three  days  after 
an  operation.  The  wound  being  healthy,  the  surgeon  is  at  a 
loss  to  account  for  the  disturbance.  Finally,  a  cathartic  is  ad- 
ministered, the  bowel  is  cleansed  of  accumulated  feces,  and 
immediately  the  temperature  returns  to  normal. 

In  the  treatment  of  auto-intoxication  it  is  necessary  to 
correct  errors  in  diet,  prohibit  the  use  of  alcoholic  stimulants, 
and  have  the  patient  take  only  such  foods  as  can  be  digested 
easily.  As  a  special  diet  milk  is  to  be  recommended.  Experi- 
ence has  proven  that  it  is  opposed  to  all  sources  of  intoxication 
and  checks  auto-intoxication  due  to  intestinal  putrefaction. 

To  prevent  the  abnormal  production  and  absorption  of 
poisons,  intestinal  antiseptics,  both  local  and  systemic,  should 
be  employed.  Perhaps  the  best  general  antiseptics,  either 
alone  or  in  combination,  are  the  iodides  of  potassium  and  so- 
dium. The  author  has  many  times  witnessed  beneficial  results 
from  the  continued  use  of  these  drugs  in  cases  where  the  sys- 
tem was  saturated  with  poisons.  Many  drugs  are  highly  com- 
mended as  intestinal  antiseptics.  Such  are  iodine,  creosote,  ben- 
zoic acid,  boric  acid,  salol,  resorcin,  turpentine,  the  mercurials, 
etc.  In  passing  through  the  alimentary  canal  many  of  these 
undergo  changes  which  diminish  their  activity  before  they 
reach  the  colon.  The  best  results  are  usually  obtained  from 
drugs  which  remain  unchanged  throughout  their  course,  such 
as  bismuth  salicylate,  salol,  iodoform,  and  naphthalin.  When 
salicylic  acid  accumulates  in  the  blood  and  threatens  compli- 
cations, bismuth  subnitrate  may  be  substituted.  In  giving 
these  intestinal  antiseptics  it  is  not  necessary  that  the  dose 
should  be  sufficiently  large  to  kill  the  bacteria,  but  large  enough 
to  render  them  dormant,  as  it  were,  thereby  preventing  their 
multiplication.  To  neutralize  poisons  already  formed  and  to 
prevent  fermentation  and  putrefaction  the  writer  knows  of 
nothing  better  than  bismuth  subnitrate  in  combination  with 
charcoal.  He  prescribes  a  powder  containing  10  grains  (0.65 
gram)  of  each,  to  be  repeated  at  short  intervals  until  there  is 
evidence  of  relief,  such  as  a  diminution  of  tympanites  and  of 
tenderness  over  the  abdomen.  The  bismuth  seems  to  prevent 
putrefactive  fermentation,  while  the  charcoal  diminishes  the 
toxins.  Iodoform  may  be  combined  with  charcoal  or  naph- 
thalin to  accomplish  the  same  purpose.  To  diminish  fecal 
odor  and  toxicity,   Bouchard  combines  75  grains   (5   grams) 


AUTO-INFECTION  AND  AUTO-INTOXICATION  139 

of  naphthalin  with  an  equal  amount  of  sugar  made  aromatic 
with  1  or  2  drops  of  bergamot.  This  mixture  he  divides  into 
twenty  powders,  and  gives  one  every  hour.  He  claims  that 
putrefaction  within  the  intestinal  canal  may  be  completely  sup- 
pressed by  this  combination.  Much  can  be  accomplished  in 
eliminating  the  toxic  condition  of  the  intestines  by  means  of 
antiseptic  sprays  and  irrigations. 

The  last  feature  in  the  treatment  consists  in  assisting 
Nature  to  neutralize  and  eliminate  poisons  which  have  already 
entered  the  circulation.  To  accomplish  this  the  emunctories 
must  be  in  perfect  order,  for,  when  the  function  of  any  one  of 
the  excretory  organs  is  deranged,  poisons  immediately  accu- 
mulate in  such  quantities  that  Nature  can  neither  neutralize 
nor  eliminate  them.  The  blood  must  be  enriched  by  tonics,  the 
liver  and  the  kidneys  stimulated  to  renewed  activity  by  appro- 
priate medicines,  and  the  skin  kept  in  order  by  frequent  cold 
baths,  followed  by  a  brisk  toweling.  In  addition  to  this,  pa- 
tients suffering  from  auto-intoxication  must  lead  a  simple, 
regular,  active,  occupied  life,  and  should  not  be  allowed  to  seek 
solitude  and  brood  over  their  condition. 


LITERATURE  ON  AUTO-INFECTION 


Bouchard,  Ch.;  "Auto-intoxication  in  Disease."  The  F.  A.  Davis  Company, 
1894. 

Hickman,  J.  W.,  Tacoma,  Wash.:    "Auto-infection,"  Medical  Sentinel. 

Ingersoll:    The  Critique  (Denver),  Feb.,  1899. 

Keyes,  Edward  L.,  New  York  City:  "Nephritis  in  its  Surgical  Aspects,"  Ameri- 
can Journal  of  the  Medical  Sciences,  June,  1894. 

Park,  Roswell,  Buffalo,  N.  Y.:  "The  Importance  to  the  Surgeon  of  Familiar- 
ity with  the  Bacillus  Coli  Communis,"  Annals  of  Surgery,  Sept.,  1893. 
"Lectures  on  Surgical  Pathology."  J.  H.  Chambers  &  Company, 
St.  Louis,  1892. 

Sternberg,  G.  M.,  Washington,  D.  C. :  "The  Bacteriology  of  Pyelonephritis," 
American  Journal  of  the  Medical  Sciences,  June,  1894. 

Stuver:    Denver  Medical  Times,  Feb.,  1899. 

Verden,  J.  E.,  Indianapolis:  "Auto-infection  from  the  Intestinal  Canal,"  In- 
diana Medical  Journal,  July,  1893. 

Welch,  William  H.,  Baltimore,  Md.:  "Conditions  Underlying  the  Infection  of 
Wounds,"  Transactions  of  the  Congress  of  American  Physicians  and 
Surgeons,  vol.  ii,  1889. 


CHAPTER  IX 

CHRONIC  DIARRHEA  DUE  TO  DISEASE  OF  THE 
COLON  AND  RECTUM 

In  the  chapter  on  symptomatology  of  rectal  disease  it  is 
stated  that  diarrhea  (frequent  stools)  is  a  common  symptom 
of  certain  rectal  affections.  It  is  the  purpose  of  the  present 
chapter  to  consider  this  form  of  diarrhea  in  detail,  to  point  out 
its  importance  as  a  manifestation  of  disease  of  the  lower  bowel, 
and  to  discuss  the  local  treatment  to  be  employed  for  its  relief. 
Each  year  the  author  treats  many  patients  for  the  relief  of 
some  rectal  trouble  of  which  diarrhea  is  a  persistent  symptom. 
These  sufferers  usually  give  a  history  of  weeks  or  months  of 
unsuccessful  internal  medication,  which  was  undoubtedly  due 
to  the  fact  that  the  frequent  stools  were  dependent  upon  local 
disease  of  some  part  of  the  terminal  colon.  Those  patients 
coming  under  the  care  of  the  writer  were  permanently  relieved 
by  some  trivial  operation  or  by  topic  applications.  The  author 
has  also  treated  patients  in  whom  the  irritating-  discharges  of 
an  antecedent  diarrhea  caused  a  rectal  disease  by  passage  over 
the  sensitive  mucous  membrane.  In  such  cases,  when  the 
original  cause  is  removed  and  the  rectal  disease  remains  un- 
cared  for,  the  latter  becomes  an  independent  source  of  irrita- 
tion, excites  peristalsis  and  frequent  stools,  and  thus  produces 
a  condition  in  every  way  similar  to  that  from  which  it  origi- 
nated. Any  one  of  the  diseases  below  enumerated,  located 
either  in  the  rectum,  sigmoid,  or  colon,  will  cause  "chronic 
diarrhea."  For  this  reason  the  author  will  discuss  them  sep- 
arately in  order  that  their  diagnostic  significance  may  the  more 
fully  be  pointed  out. 


1. 

Chronic     proctitis     (ca- 

4. Malignant  disease. 

tarrh). 

5.  Prolapse. 

2. 

Stricture. 

6.   Polyps. 

3. 

Ulceration. 

7.  Fecal  impaction. 

8.  Deviated 

coccyx. 

Chronic  Inflammation  of  the  rectum  is  quite  common,  and 
is  due  principally  to  the  functions  of  this  organ.     By  the  time 
(140) 


CHRONIC  DIARRHEA  141 

the  intestinal  contents  reaches  the  lower  bowel,  it  is  firm  and 
frequently  nodular ;  it  remains  in  the  colon  a  much  longer  time 
than  in  other  parts  of  the  intestine,  and  during  peristalsis  is 
frequently  jostled  from  side  to  side  against  the  sensitive  mu- 
cous membrane.  Again,  the  feces  undergo  certain  putrefactive 
changes,  thus  exposing  any  unsound  portions  of  the  mucosa  to 
the  action  of  septic  organisms  contained  therein;  as  a  result, 
an  inflammation  accompanied  by  frequent  discharge  of  large 
quantities  of  mucus  is  started,  which  is  frequently  mistaken  for 
ordinary  diarrhea. 

A  Stricture  from  any  cause  sufficiently  marked  to  produce 
mechanic  obstruction  will  cause  diarrheal  symptoms  for  two 
reasons :  first,  because  of  ulceration  at  and  above  the  point  of 
constriction,  the  nerve-filaments  are  exposed  to  the  feces,  a 
peristalsis  is  started  and  continued,  resulting  in  frequent  stools; 
second,  liquid  feces  pass  the  obstruction,  while  those  more  solid 
accumulate  above  it,  become  hard,  irregular  in  shape,  and  cov- 
ered with  a  glairy  mucus.  As  a  result- of  pressure  exerted  by 
the  solid  feces,  there  is  constant,  but  ineffectual,  eft'ort  to  empty 
the  bowel ;  the  mass  acts  as  a  valve,  inducing  abnormal  peri- 
stalsis and  straining,  which  cause  frequent  discharges  of  liquid 
feces  without  affording  any  relief,  although  most  of  the  pa- 
tient's time  is  spent  in  the  closet. 

Anyone  who  has  done  much  rectal  surgery  must  have 
noticed  the  frequency  of  chronic  diarrhea  as  a  symptom  of 
ulceration  of  the  rectum  and  sigmoid.  When  the  mucous  mem- 
brane becomes  denuded  from  any  cause  it  soon  becomes  irri- 
table, and  any  little  particles  of  fecal  matter  lodging  at  such  a 
point,  or  the  passage  over  it  of  an  irritating  discharge,  will 
prove  sufficient  to  excite  frequent  and  prolonged  peristalsis, 
resulting  in  tenesmus  and  frequent  stools. 

Because  of  the  obstruction  and  accompanying  ulceration, 
diarrhea  constitutes  one  of  the  most  troublesome  symptoms 
encountered  in  the  treatment  of  cancer  of  the  rectum  or  colon. 
The  constant  straining  which  these  sufferers  have  to  bear  is 
distressing  to  behold.  The  author  has  had  under  his  care  many 
patients  suffering  from  cancerous  stricture  of  the  rectum  mani- 
festing the  above  symptoms  who  have  been  treated  for  diar- 
rhea for  months,  rectal  disease  never  having  been  suspected. 

Rectal  Prolapse,  or  invagination  of  the  rectum  or  sigmoid, 
acts  as  a  source  of  irritation.     It  is  frequently  mistaken  and 


142  DISEASES  OF  THE  RECTUM  AND  ANUS 

treated  for  chronic  diarrhea,  because  of  the  frequent  discharge 
of  large  quantities  of  mucus. 

Polyps,  when  located  in  the  lower  bowel,  excite  an  abnor- 
mal secretion  of  mucus,  which  is  passed  at  frequent  intervals, 
and  may  be  mistaken  for  a  chronic  diarrhea  from  other  causes. 

It  is  a  well-known  fact  that  diarrhea  is  sometimes  a  symp- 
tom of  fecal  impaction,  for  the  reason  that  well-formed  feces 
cannot  get  by  the  impacted  mass.  After  a  time  the  latter  acts 
as  a  source  of  irritation,  excites  peristalsis,  and  then  permits 
only  liquid  feces  to  pass  through  or  around  it  at  frequent  in- 
tervals. 

A  Deformed  Coccyx  pointing  forward  or  backward  may  pro- 
duce symptoms  simulating  chronic  diarrhea  as  a  result  of  reflex 
disturbances.  Usually  it  points  forward  and  pushes  the  rectum 
inward,  thereby  offering  an  obstruction  to  the  free  exit  of  the 
feces.  The  author  had  under  his  care  two  patients  who,  for 
a  number  of  years,  had  been  unsuccessfully  treated  for  chronic 
diarrhea.  In  both  instances  ulceration,  which  penetrated  the 
rectum,  was  present  over  the  end  of  the  bone.  In  each  the 
coccyx  was  excised,  the  opening  closed,  and  the  patient  made 
a  rapid  and  uninterrupted  recovery. 

The  condition  of  the  rectum  in  cases  of  chronic  diarrhea 
depends  upon  the  disease  which  produces  it,  as  well  as  the 
length  of  time  it  has  existed.  When  due  to  a  prolapse,  polyp, 
colitis,  proctitis,  or  an  impaction,  the  mucous  membrane  will  ap- 
pear congested,  thickened,  and  covered  with  thick  glairy  mu- 
cus, pus,  or  both;  when  not  speedily  corrected,  the  membrane 
soon  loses  its  smooth,  velvety  appearance,  becomes  much  thick- 
ened, indurated,  and  firmly  attached  to  the  submucous  tissues, 
sometimes  forming  long,  tubular  stricture.  When  ulceration, 
stricture,  and  malignancy  are  the  cause,  the  mucous  membrane 
in  the  earher  stages  looks  very  much  like  that  just  referred  to; 
when,  however,  the  ulceration  begins  to  extend,  it  loses  its 
smoothness,  and  appears  ragged  to  the  touch ;  when  stricture 
is  present  the  finger  introduced  into  the  bowel  will  meet  with 
many  irregular-shaped  nodules,  cavities,  or  cicatricial  bands, 
and  when  passed  through  the  constriction,  no  matter  whether 
the  latter  be  due  to  syphilis  or  cancer,  there  is  felt  a  sensation 
similar  to  that  produced  by  a  strong  rubber  band  placed  around 
the  end  of  the  finger. 


CHRONIC  DIARRHEA  143 

SYMPTOMS   AND   DIAGNOSIS 

Pain,  tenesmus,  and  frequent  stools  are  undoubtedly  the 
most  frequent  symptoms  that  these  sufferers  complain  of,  and 
they  vary  considerably;  in  one  case  they  will  be  mild,  in  an- 
other severe,  depending  upon  both  the  disease  and  the  extent 
to  which  it  has  progressed.  When  due  to  polyps,  prolapse,  im- 
paction, deviated  coccyx,  chronic  colitis,  or  proctitis,  the  symptoms' 
are  very  much  ahke;  in  all  probability  there  will  be  from  six 
to  ten  stools  daily,  accompanied  by  smarting,  burning  pain, 
tenesmus,  and  eversion  of  the  mucous  membrane.  When  either 
a  prolapse  or  a  polyp  is  present,  in  addition  to  the  above 
symptoms  the  patient  will  complain  of  something  protruding 
from  the  anus. 

A  microscopic  examination  of  the  feces  should  be  made  in 
every  case  (see  chapter  on  examination),  for  in  this  way  many 
valuable  points  can  be  gained  which  will  be  of  assistance  in 
clearing  up  the  diagnosis.  The  stools  are  usually  liquid  or 
semisolid  and  composed  largely  of  mucus,  which  is  now  and 
then  mixed  with  pus  and  blood,  when  ulceration  has  com- 
menced. Some  of  these  patients  occasionally  complain  of  pain 
and  uneasiness  along  the  small  or  large  intestine,  followed  on 
the  morrow  by  the  passage  of  shreds  of  mucus  or  perfect  casts 
of  the  bowel,  which  at  first  appear  to  be  the  mucous  membrane ; 
when  pulled  apart,  however,  the  latter  prove  to  be  a  thick  ex- 
udation resembling  the  false  membrane  seen  in  diphtheria. 
Here  we  have  a  membranous  enterocolitis  supposed  to  be  of 
nervous  origin,  for  its  pathology  remains  obscure.  When 
there  is  prolonged  irritation  of  the  mucous  membrane  from 
any  of  the  diseases  enumerated,- the  sphincters  alternately  con- 
tract and  relax,  causing  the  patient  much  annoyance;  some- 
times these  muscles  become  exhausted  and  remain  passive, 
necessitating  the  wearing  of  a  napkin  to  prevent  escape  of  feces. 
In  addition  to  the  symptoms  mentioned,  there  may  be  reflex 
disturbances  in  the  neighboring  organs,  and  pains  in  the  back, 
abdomen,  and  down  the  limbs.  The  most  annoying  symptoms, 
however,  are  almost  constant  straining  and  never-ceasing  desire 
to  empty  the  bowel.  These  sufiferers  have  a  haggard  expres- 
sion, sallow  complexion,  and  hollow  eyes;  they  are  extremely 
nervous,  and  many  acquire  the  habit  of  resorting  to  an  opiate 
for  relief  of  their  suffering. 

It  is  easy  to  make  a  dia^osis  in  these  cases  if  the  his- 


144  DISEASES  OF  THE  RECTUM  AND  ANUS 

tory  is  first  secured,  and  then  a  thorough,  ocular,  digital,  mi- 
croscopic, specular,  and  procto-colonic  examination  made. 
Chronic  catarrh  will  be  recognized  by  the  appeara,nce  of  the 
mucous  membrane :  it  is  congested,  thickened,  and  covered 
with  thick,  tenacious  mucus.  A  sweep  of  the  finger  around 
the  rectal  wall  will  easily  detect  the  presence  of  a  polyp,  be- 
cause of  its  attachment  by  a  long,  narrow  pedicle.  Rectal  pro- 
lapse cannot  be  mistaken  for  other  conditions  because  of  the 
everted  mucous  membrane,  globular  form  of  the  tumor,  the 
central  sht,  and  the  fact  that  the  entire  circumference  of  the 
bowel  is  involved.  When  ulceration  is  present  the  mucous 
membrane  is  irregular  and  thickened  to  the  touch,  and  when 
a  speculum  is  used  the  ulcers  are  readily  seen.  Malignant  dis- 
ease and  stricture  are  recognized  by  the  diminution  in  the  caliber 
of  the  bowel  as  a  result  of  cicatricial  bands  or  from  hard,  nod- 
ular tumors  accompanied  with  ulceration  at  and  above  the  con- 
striction. 

The  prognosis  of  diarrhea  dependent  upon  either  chronic  ca- 
tarrh, prolapse,  polyp,  or  deviated  coccyx  is,  under  ordinary  cir- 
cumstances, good.  When  due  to  benign  stricture  and  ulceration 
it  is  good  in  so  far  as  a  fatal  termination  is  concerned.  There 
are  cases,  however,  which  will  require  long  treatment,  and 
some  in  which  nothing  beyond  a  fairly  comfortable  existence 
can  be  promised.  In  malignant  disease  the  prognosis  is  exceed- 
ingly unfavorable,  and,  unless  the  disease  is  removed  at  its 
inception,  death  will  follow  in  a  short  time.  The  life  of  cancer 
patients  may,  however,  be  extended  and  their  existence  made 
more  comfortable  if  they  will  submit  to  proper  treatment. 


TREATMENT 

Since  the  treatment  of  those  rectal  diseases,  such  as 
chronic  proctitis,  stricture,  ulceration,  etc.,  which  give  rise  to 
diarrheal  symptoms  has  been  given  in  detail  in  chapters  de- 
voted to  these  afifections,  it  is  unnecessary  to  give  here  more 
than  a  general  outline  of  the  treatment. 

The  diet  should  be  restricted  to  non-irritating,  easily  di- 
gestible foods,  such  as  soup,  soft-boiled  eggs,  pure  beef-juice, 
broiled  steak,  and  plenty  of  milk  in  those  cases  in  which  it  does 
not  produce  an  overabundance  of  gas.  Regular  hours  for  eat- 
ing, sleeping,  exercising,  and  attending  to  the  calls  of  Nature 


CHRONIC  DIARRHEA  145 

must  be  insisted  upon,  for  it  is  a  well-known  fact  that  irregu- 
larities in  living  are  responsible  for  many  of  these  conditions. 

There  are  two  essential  features  in  the  treatment  of  chronic 
proctitis:  first,  absolute  rest  in  bed;  second,  absence  from  the 
bowel  of  all  irritating  ingesta.  In  addition,  the  rectum  and 
colon  must  be  flushed  daily  with  copious  injections  of  boiled, 
filtered  water  and  antiseptic  and  astringent  solutions.  The 
writer  has  had  splendid  results  from  the  semiweekly  injection 
through  a  colon-tube  of  20  to  30  grains  (130  to  200  centigrams) 
of  silver  nitrate  to  the  quart  (1  liter)  of  water.  The  days  on 
which  silver  nitrate  is  not  used  the  colon  may  be  irrigated 
with  alum-water, — say,  a  teaspoonful  (4  cubic  centimeters)  to 
the  quart  (1  liter).  There  are  many  other  remedies  that  will 
render  good  service.  A  favorite  combination  of  the  author's  is 
biborate  of  soda,  V2  drachm  (2  cubic  centimeters) ;  fluid  extract 
of  krameria,  ^/a  ounce  (15  cubic  centimeters);  water,  3  ounces 
(90  cubic  centimeters),  to  be  injected  into  the  colon  and  left 
there  for  half  an  hour.  Olive-oil,  1  pint  (500  cubic  centime- 
ters) ;  bismuth  subnitrate,  3  ounces  (90  grams) ;  iodoform,  1 
drachm  (4  grams),  is  another  time-tried  remedy.  From  2  to  3 
ounces  (60  to  90  cubic  centimeters)  of  this  mixture,  used 
every  other  day,  has  a  very  soothing  and  beneficial  effect.  Un- 
less the  operator  is  skilled  in  this  work  it  is  not  an  easy  thing 
to  insert  the  colon-tube,  because  of  the  obstruction  offered  by 
Houston's  "valves,"  and  the  tortuosity  of  the  intestine;  it  is 
most  important  to  have  a  good,  strong,  reliable  syringe.  A 
fountain-syringe  will  do  to  flush  out  the  rectum,  but,  when 
heavy,  thick,  oily  solutions  are  to  be  thrown  high  into  the  colon, 
a  Davidson  or  piston-  syringe  is  preferable,  for  two  reasons :  In 
the  first  place,  when  attached  to  the  tube,  if  the  end  of  the  latter 
gets  caught  under  one  of  the  "valves"  or  a  fold  of  the  mem- 
brane, water  can  be  forced  through  with  sufficient  force  to  over- 
come the  obstruction  and  the  tube  will  pass  upward  into  the 
sigmoid  and  colon.  In  the  second  place,  the  exact  amount  of 
medication  it  is  desirable  to  use  can  be  thrown  into  the  bowel ; 
on  the  other  hand,  when  a  fountain-syringe  is  used,  if  the  mixt- 
ure is  heavy,  a  considerable  portion  is  lost  in  the  tubing. 

Stricture  of  the  rectum  requires  both  palliative  and  opera- 
tive treatment.  The  object  of  the  first  is  to  alleviate  pain  and 
give  rest  to  the  patient.     It  is  best  secured  by  keeping  the 

bowel  open  and  clean  by  flushing  with  antiseptic  solutions,  to 

10 


146  DISEASES  OF  THE  RECTUM  AND  ANUS 

be  followed  by  soothing  lotions,  topic  applications,  and  oint- 
ments. The  best  operative  procedures  for  the  relief  of  strict- 
ure are  three  in  number,  viz.:  (1)  colotomy;  (2)  posterior 
proctotomy;    (3)  dilatation,  either  gradual  or  forcible. 

By  the  first  a  new  outlet  is  made  for  the  feces;  the  diar- 
rheal symptoms  disappear,  because  the  source  of  irritation  and 
obstruction  are  removed.  In  the  second  and  third,  relief  is 
obtained  because  after  either  operation  there  is  no  obstruction 
to  the  passage  of  the  solid  feces,  and  the  ulceration  present 
which  excites  peristalsis  can  soon  be  cured.  In  cancer  the  in- 
dications for  treatment  are  almost  identic  with  those  of  strict- 
ure; about  the  only  exception  is  when  the  growth  is  removed 
by  excision. 

The  treatment  of  polyps  is  simple :  they  are  caught,  pulled 
down,  clamped,  cut  off,  and  cauterized ;  or  they  may  be  twisted 
off  with  a  pair  of  forceps,  or  ligated  and  excised. 

A  prolapse,  when  extensive,  will  require  an  operation.  The 
simplest  and  best  is  linear  cauterization  with  a  Paquelin  cau- 
tery, making  the  lines  half  an  inch  (1.27  centimeters)  apart  and 
about  two  inches  (5.04  centimeters)  long,  extending  down  and 
into  the  sphincter-muscle.  Excision  of  a  portion  of  the  rectum 
has  been  resorted  to,  but  has  not  given  satisfaction.  Mild  cases, 
especially  in  children,  can  be  cured  by  astringent  injections, 
such  as  alum,  zinc,  and  black-oak  bark;  besides  this  the  patient 
must  assume  the  recumbent  position  during  defecation  to  pre- 
vent too  much  straining ;  during  the  intervals  of  defecation  the 
buttocks  should  be  firmly  strapped  together  with  adhesive 
plaster. 

Simple  ulceration  of  the  rectum  or  sigmoid  will  heal  if  kept 
clean  and  stimulated  by  such  remedies  as  silver  nitrate,  15  or 
20  grains  (1.30  grams)  to  the  ounce  (30  cubic  centimeters) ; 
the  balsam  of  Peru,  fluid  extract  of  krameria,  calomel,  or  the 
stearate  of  zinc  with  iodoform,  menthol,  or  ichthyol.  When 
chronic,  it  will  be  necessary  to  resort  to  radical  measures,  and 
either  divulse  or  incise  the  sphincter-muscle  and  curette  the 
ulcers ;  the  after-treatment  consists  in  keeping  the  rectum  clean 
and  applying  stimulating  remedies. 

For  immediate  relief  of  fecal  impaction  the  most  reliable 
remedies  are  copious  injections  of  water,  soap-suds,  oil,  or  tur- 
pentine ;  these  should  be  continued  every  fev/  hours  until  the 
fecal  mass  is  removed.    When  the  impaction  is  in  the  sigmoid, 


CHRONIC  DIARRHEA  147 

massage  will  sometimes  assist  in  breaking  up  the  accumulation ; 
on  the  other  hand,  when  it  is  situated  low  down  in  the  rectum 
and  enemata  fail  to  bring  it  away,  it  will  be  necessary  to  divulse 
the  sphincter,  insert  the  fingers,  and  break  up  and  remove  the 
mass  in  sections. 

When  the  end  of  the  coccyx  is  misplaced  sufficiently  to 
cause  irritation  and  bring  on  diarrhea,  an  incision  should  be 
made  down  to  the  bone  and  one,  two,  or  three  sections  of  the 
coccyx  excised,  as  the  case  demands. 

In  conclusion,  the  author  wishes  to  state  that  he  does  not 
believe  that  all  cases  of  chronic  diarrhea  are  due  to  disease  of 
the  terminal  portion  of  the  bowel.  He  is  of  the  opinion,  how- 
ever, that  the  source  of  irritation  producing  frequent  evacua- 
tions is  more  frequently  located  in  the  rectum  than  is  generally 
supposed.  For  this  reason  he  recommends  examination  of  the 
rectum  and  colon  in  every  case  in  which  internal  medication  fails 
to  relieve  the  diarrheal  symptoms  within  two  months.  The 
practitioner  who  does  this  regularly  will  be  amply  repaid  for 
his  trouble;  he  will  make  a  correct  diagnosis  and  be  able  to 
cure  many  of  those  sufferers  who  drift  from  one  physician  to 
another  without  receiving  any  benefit. 

ILLUSTRATIVE   CASES 

Case  I.  Chronic  Diarrhea  Caused  by  Ulceration. — This  case  is  pre- 
sented because  of  its  interest  to  both  the  sui'geon  and  general  practitioner. 
The  patient  was  a  married  lady  30  years  old.  She  stated  that  she  had 
suffered  from  diarrhea  for  five  years,  often  going  to  the  closet  eight  or 
ten  times  a  day;  various  medicines  prescribed  by  prominent  physicians 
had  been  experimented  with  and  patent  nostrums  had  been  taken,  all  to 
no  purpose.  A  Chinese  doctor  had  been  consulted  and  failed  to  effect  a  cure. 
Osteopathy  and  Christian  Science  Avere  then  tried  with  negative  result.  Be- 
coming discouraged,  she  appealed  to  her  family  physician,  who  referred  her 
to  me  for  treatment.  An  examination  revealed  the  presence  of  several  ulcers 
extending  from  the  upper  margin  of  the  external  sphincter  to  the  upper  por- 
tion of  the  internal.  They  varied  in  size  from  the  .diameter  of  a  green  pea  to 
one  inch  (2.54  centimeters),  the  largest  one  being  on  the  posterior  surface. 
After  the  patient  was  anesthetized  and  the  sphincter  divulsed,  I  curetted  the 
ulcers  and  incised  the  large  one,  which  was  situated  directly  over  the  sphincter- 
muscle.  The  ulcerated  area  was  then  brushed  over  with  silver  nitrate.  On 
the  third  day  after  operation  the  patient  had  a  fecal  movement.  The  rectum 
was  then  irrigated  and  silver  nitrate  again  applied  to  the  ulcer.  The  same 
procedure  was  carried  out  every  three  days  for  a  month,  when  the  ulcers  were 
entirely  healed.  During  this  time  there  was  not  the  slightest  tendency  td 
diarrhea.     At  the  end  of  six  weeks  the  patient  disappeared,  and  was  lost  sight 


148  DISEASES  OF  THE  RECTUM  AND  ANUS 

of  for  twelve  months,  when  she  called  at  my  office  and  informed  me  of  her 
entire  recovery. 

Case  II.  Chronic  Diarrhea  Caused  by  Rectal  Polyps.  —  Mr.  W.  B., 
photographer,  suffering  from  a  chronic  diarrhea  of  four  years'  standing,  came 
to  me  with  the  following  symptoms:  He  had  from  four  to  ten  dejections 
daily,  which  were  accompanied  by  much  pain  and  straining.  The  stools 
were  always  liquid,  and  consisted  largely  of  mucus.  The  bowel  felt  as  if 
some  foreign  body  were  within  the  rectum,  exciting  almost  constant  irrita- 
tion and  desire  to  go  to  stool.  On  account  of  the  large  quantities  of  mucus 
discharged,  some  local  disease  of  the  colon  or  the  rectum  was  suspected, 
and  a  digital  examination  was  therefore  at  once  made.  Immediately  upon 
introduction  of  the  finger,  a  large,  soft,  polypoid  tumor  the  size  of  an  English 
walnut  was  detected.  Further  examination  revealed  the  presence  of  another 
polyp  of  equal  size.  The  finger  could  be  passed  around  these  growths,  and 
their  attachment  to  the  rectal  wall  was  located  with  little  difficulty. 

Treatment. — The  patient  was  chloroformed,  placed  in  lithotomy-position, 
and  the  rectum  irrigated.  The  polyps  were  seized  in  turn,  pulled  downward, 
and  the  author's  clamp  tightly  adjusted  to  the  pedicle  at  its  junction  with 
the  raucous  membrane.  That  portion  of  the  growth  external  to  the  clamp  was 
then  excised  (as  in  the  operation  for  hemorrhoids)  and  the  stump  carefully 
cauterized  with  a  Paquelin  cautery.  The  patient  was  placed  in  bed  and  the 
nurse  instructed  to  keep  him  quiet  for  thirty-six  hours.  On  the  third  day  his 
bowels  acted,  and  he  Avas  allowed  to  walk  around.  At  the  end  of  one  week 
he  returned  to  the  photograph  gallery,  and  from  that  time  to  the  present,  two 
years  after  the  operation,  he  has  had  no  diarrhea.  This  case  is  offered  for  the 
reason  that  it  proves  beyond  doubt  that  the  frequent  stools  were  the  result 
of  the  irritation  excited  by  the  presence  of  the  polyps,  and  not  from  any 
abnormal  condition  of  the  stomach  or  small  intestine. 


CHAPTER  X 

DISEASES,  INJURIES,  AND  TUMORS  OF  THE  COCCYX 

The  diseases  and  injuries  of  the  os  coccyx  have  received 
but  slight  attention  at  the  hands  of  the  general  practitioner, 
surgeon,  and  rectal  specialist.  The  author  is  not  acquainted 
with  a  single  work  devoted  to  diseases  of  the  rectum  and  anus 
or  general  surgery  which  contains  a  description  of  the  various 
ailments  common  to  this  region.  Yet  he  has  had  many  pa- 
tients come  to  him  who  were  suffering  from  intense  pain  in  the 
rectum — ulceration,  hemorrhages,  diarrhea,  constipation,  ab- 
scess, fistulas,  and  other  pathologic  conditions  of  the  lower 
bowel — induced  by  a  coccygeal  tumor,  or  a  deformed,  fract- 
ured, or  necrosed  coccyx. 

In  every  such  case  a  prompt  recovery  followed  the  trivial 
operation  necessary  for  the  removal  of  the  irritation.  •   | 

The  good  results  thus  obtained  have  induced  the  author 
to  set  apart  a  separate  chapter  for  the  consideration  of  this 
class  of  affections.  They  will  be  described  under  the  following 
headings : — 

1.  Malformations     of     the       5.   Sacro-coccygeal    tumors 

coccyx.  and  cysts. 

2.  Coccygeal  body  and  its       6.  Syphilis  of  the  coccyx, 

diseases.  7.  Tuberculosis  of  the  coc- 

3.  Coccygodynia.  cyx. 

4.  Fractures,     dislocations, 

injuries,    and    necrosis 
of  the  coccyx. 

MALFORMATION    (ABNORMALITIES)    OF  THE   COCCYX 

It  not  infrequently  happens  that  there  is  a  congenital  de- 
formity of  the  coccyx,  and  occasionally  it  is  entirely  absent. 
The  OS  coccyx  may  deviate  to  either  side :  lateral  curvature; 
forward  against  the  rectum :  anterior  curvature  (Fig.  46) ;  or 
backward,  showing  prominently  beneath  the  skin :  posterior 
curvature  (Fig.  47).  In  forzvard  deformity  the  rectum  is  caught 
between  fecal  accumulations  and  the  end  of  the  bone,  causing 

(149) 


150 


DISEASES  OF  THE  RECTUM  AND  ANUS 


ulceration,  and  sometimes  perforation  and  projection  of  the 
tip  of  the  bone  into  the  bowel.  In  posterior  curvature  the  skin 
over  the  bone  may  be  normal,  bluish  in  color,  or  ulcerated, 
depending  upon  the  amount  of  tension  and  irritation. 

Symptoms. — Pain  in  the  neighborhood  of  and  over  the  end 
of  the  bone  is  the  most  frequent  manifestation  of  a  deformed 
coccyx.  It  is  greatly  increased  when  the  patient  lies  upon  a 
hard  cot,  sits  on  a  hard  chair,  or  rides  in  a  street-car.  When 
anterior  displacement  is  present,  constipation  and  defecation 
aggravate  the  condition.  Suffering  is  greatest  just  before 
stool,  and  is  greatly  relieved  by  it.     When  there  is  ulceration 


Pig.  46.— Diagrammatic  Drawing  Showing  Deviation  of  the  Coccyx  Anteriorly. 


and  the  end  of  the  bone  projects  into  the  bowel,  there  will  be 
discharges  of  pus,  blood,  and  mucus,  and  frequently  chronic 
diarrhea.  In  some  instances  it  has  been  necessary  to  fracture 
the  bone  or  remove  it  during  labor  in  order  to  deliver  the  child. 
One  case  of  severe  scalp  wound  in  an  infant,  caused  during 
labor  by  a  deformed  coccyx,  has  been  recorded.  Chorea  and 
other  nervous  phenomena  occur  sooner  or  later  in  these  cases. 
Treatment. — The  offending  bone  should  be  removed  in  the 
manner  described  elsewhere  in  this  chapter.  When  labor  is 
delayed  by  a  deformed  coccyx,  the  bone  should  be  pushed 
backward  with  the  thumb  and  fractured.  It  will  give  way  with 
a  snap. 


DISEASES,  INJURIES,  AND  TUMORS  OF  COCCYX 


151 


Floating  Coccyx  is  the  name  given  to  this  bone  where  it  is 
freely  movable  in  all  directions  and  appears  to  be  detached 
from  the  sacrum.  Such  a  condition  may  be  congenital  or  the 
result  of  a  sudden  and  severe  injury. 

Treatment.  —  Because  of  the  location  and  activity  of  the 
ligaments  and  muscles  attached,  it  is  a  very  difficult  matter 
to  fix  and  retain  the  coccyx  in  its  natural  situation.  This  may 
be  attempted  by  sutures  or  plugging  the  rectum;  the  best 
results,  however,  are  derived  from  complete  extirpation  at  the 
earliest  opportunity. 


Fig.  47. — Diagrammatic  Drawing  Showing  Deviation  of  the  Coccyx  Posteriorly. 


Entire  Absence  of  the  Coccyx  is  a  rare  form  of  congenital 
deformity.  The  author  has  seen  but  two  cases,  and  both  of 
these  in  men  who  consulted  him  for  relief  from  some  other 
painful  affection  of  the  anus.  Both  were  congenital,  and  did 
not  interfere  in  any  way  with  the  functions  of  the  anus,  rectum, 
or  bladder.  Indeed,  they  did  not  cause  any  disturbance  of 
sufficient  importance  to  attract  attention  to  these  parts.  The 
place  of  the  bone  was  filled  by  dense  fascia,  with  which  the 
ligaments  and  muscles  usually  attached  to  the  coccyx  appeared 
to  be  continuous.  The  history  of  one  of  these  cases  is  given 
at  the  end  of  this  chapter. 


152  DISEASES  OF  THE  RECTUM  AND  ANUS 

COCCYGEAL  BODY  AND  ITS  DISEASES 

Synonyms. — Glandula  coccygea ;  Luschka's  gland ;  coccyg- 
eal gland ;   glomeruli  arteriosi  coccygei. 

History  and  Anatomy.  —  In  1859  Luschka  discovered  a 
small  body,  of  split-pea  size,  upon  the  inner  surface  of  the 
second  coccygeal  segment,  just  in  the  interval  between  the 
attachments  of  the  levator  ani  muscle.  It  was  attached  by  a 
pedicle  composed  of  small,  club-shaped  branches  of  the  middle 
sacral  artery  and  filaments  of  the  sympathetic  nerve. 

Sometimes  it  appeared  as  one  large  corpuscle ;  at  others 
it  seemed  to  be  composed  of  a  number  of  corpuscles  held  to- 
gether by  connective  tissue  inclosing  glandular  elements  (hence 
the  name),  and  received  its  nerve-supply  from  the  coccygeal 
ganglion.  In  1864  Arnold  disproved  the  glandular  theory  of 
Luschka  by  injecting  the  middle  sacral  artery,  completely  fill- 
ing every  part  of  the  coccygeal  body,  and  demonstrating  that 
it  was  composed  of  the  terminal  branches  of  the  artery,  and 
resembled  in  appearance  a  bunch  of  grapes.  He  then  renamed 
it  the  ''glomeruli  arteriosi  coccygei^  Two  years  later  Krause 
and  Meyer  verified  Arnold's  experiments,  and  claimed  to  have 
discovered  a  similar  body  in  the  monkey.  Banks,  in  the  same 
year,  demonstrated  the  constancy  of  this  body,  and  gave  the 
following  description  of  it:  Structure:  "It  had  a  gelatinous 
appearance;  one  section  contained  numerous  cavities,  filled 
with  cells  and  granules  encircled  by  nucleated  fibers,  and  the 
twigs  of  the  artery  had  the  usual  endothelial  lining."  Arnold, 
Krause,  and  Banks  held  that  the  coccygeal  body  had  no  specific 
function  beyond  being  an  appendage  and  a  help  to  the  middle 
sacral  artery,  as  are  the  caudal  and  auxiliary  hearts  in  some 
animals,  and  neither  believed  it  to  be  the  vestigeal  remains  of 
a  fetal  organ. 

This  gland  (or  body)  resembles  in  some  respects  the  ca- 
rotid gland ;  the  descriptions  of  it  found  in  modern  text-books 
on  anatomy  are  meager,  unsatisfactory,  and  furnish  little  in- 
formation beyond  what  is  obtainable  from  descriptions  given 
by  the  original  investigators  already  mentioned. 

Pathology. — Very  little  is  known  of  the  pathologic  changes 
which  take  place  in  this  little  body.  Luschka  held  to  the 
opinion  that  the  peculiar  pains  situated  in  the  neighborhood 
of  the  coccyx,  known  as  coccygodynia,  and  which  are  so  com- 
mon in  women,  are  due  to  inflammation  of  this  body.      He 


DISEASES,  INJURIES,  AND  TUMORS  OF  COCCYX  153 

further  taught  that  most,  if  not  all,  perineal  cysts  had  their 
origin  at  this  point.  Banks  was  not  in  accord  with  the  views 
of  Luschka.  He  believed  that  the  coccygeal  body  was  the 
starting-point  of  cysto-sarconiatous  tumors.  The  author  is  of  the 
opinion  that  the  coccygeal  gland  occasionally  becomes  inflamed 
and  swollen  from  exposure,  injury,  the  pressure  of  tumors  or 
hardened  feces,  and  inflammatory  or  other  destructive  changes 
of  the  rectum  which  extend  to  this  region.  It  may  be  that 
posterior  fistulas  which  have  their  outlet  near  the  tip  of  the 
coccyx  are  caused  by  changes  in  this  body;  certainly  their 
etiology  cannot  always  be  accounted  for  in  other  ways.  The 
author  has  removed  two  cysts  of  orange  size  from  the  peri- 
neum, one  in  a  man  and  the  other  in  a  woman,  both  of  which 
were  closely  attached  to  the  lower  and  inner  surface  of  the 
coccyx,  and  it  is  not  improbable  that  they  were  caused  by  a 
degeneration  of  Luschka's  gland. 

Symptoms. — When  inflamed,  the  coccygeal  gland  becomes 
swollen,  and  tender  on  pressure.  Pain  is  increased  by  moving 
the  coccyx  and  also  before  and  during  defecation,  especially 
when  the  feces  are  hard  and  nodular ;  it  is  aching  in  character 
and  located  at  the  lower  end  of  the  spine. 

Diagnosis. — When  the  gland  is  enlarged  it  can  be  located 
with  comparative  ease  by  passing  the  right  index  finger  in  the 
bowel  and  then  backward,  when  the  coccyx  is  seized  between 
it  and  the  thumb  of  the  same  hand  on  the  outside.  It  varies 
under  such  circumstances  from  pea  to  cherry  size,  and  is  pain- 
ful when  pressed  upon.  It  is  quite  firm,  round,  and  is  slightly 
movable.  Such  at  least  were  the  sensations  imparted  to  the 
finger  of  the  author  in  two  cases  diagnosticated  as  inflamma- 
tion of  this  body. 

Treatment.  —  Relief  usually  foHows  the  application  of  the 
ice-pack  over  the  coccyx  and  cold  irrigation  per  rectum.  Hot 
applications  and  suppositories  are  also  serviceable.  When 
these  remedies  fail,  the  coccyx,  including  the  gland,  should  be 
extirpated.  Relief  will  be  prompt  and  no  unpleasant  sequels 
are  likely  to  follow. 

COCCYQODYNIA 

Pain  in  the  coccyx,  its  joints,  or  at  the  sacro-coccygeal 
articulation  is  a  frequent  persistent  and  painful  affection.  This 
condition  was  first  described  in  a  clear  and  concise  manner  by 


154  DISEASES  OF  THE  RECTUM  AND  ANUS 

Dr.  J.  C.  Nott,  of  New  York,  in  1844.  He  not  only  pointed 
out  the  principal  manifestations  of  coccygodynia,  but  suggested 
a  practical  remedy  for  its  permanent  relief,  namely:  that  of 
excision  of  all  or  a  part  of  the  coccyx.  Many  writers  have 
given  to  Prof.  J.  Y.  Simpson,  of  Edinburgh,  the  praise  for  first 
calling  attention  to  this  ailment,  notwithstanding  the  fact  that 
his  lecture  upon  this  topic  was  not  delivered  until  1859,  or 
nearly  fifteen  years  after  the  published  article  of  Dr.  Nott. 
Coccygodynia  is  common  to  both  sexes,  but  is  encountered 
more  frequently  in  women,  especially  in  those  who  have  borne 
children.  It  usually  occurs  between  the  ages  of  twenty  and 
forty  and  in  persons  of  a  nervous  temperament;  it  is  rarely 
met  with  in  old  persons  and  young  children.  It  is  found  with 
greater  frequency  in  lean  than  in  stout  individuals,  because  the 
caudal  bone  in  the  latter  is  fairly  well  protected  from  injury 
by  a  cushion  of  fat. 

Etiology  and  Pathology. — Coccygodynia  may  be  caused  by 
exposure,  rheumatic  changes  in  the  ligaments  and  muscles, 
caries,  or,  in  fact,  anything  which  results  in  an  inflammation 
of  the  coccyx,  its  periosteum  and  articulations.  Again,  it  may 
be  induced  by  spasmodic  or  prolonged  contraction  of  the  vari- 
ous muscles  and  ligaments  attached  to  the  os  coccyx.  It  is  fre- 
quently induced  by  fissures,  hemorrhoids,  and  ulceration,  as 
well  as  by  uterine,  vaginal,  and  prostatic  disturbance,  which 
excites  contraction  of  the  muscles  in  this  region.  Coccygodynia 
may  be  caused  by  constipation  when  the  fecal  accumulations 
are  hard,  nodular,  and  catch  the  rectum  between  them  and 
the  bone,  pressing  the  latter  backward.  It  may  result  from 
displacement  of  the  coccyx  by  rectal  or  coccygeal  tumors,  from 
syphilis  or  tuberculosis  of  the  os  coccyx,  inflammation  of  the 
coccygeal  body  (Luschka),  neuroses  of  the  coccygeal  plexus 
(Payer),  and  from  emotional  or  intellectual  strain  inducing 
hysteria  (Bremer). 

Symptoms.  —  Increased  pain  on  pressure  over  the  coccyx 
and  when  sitting  or  lying  down  and  when  leaning  forward. 
Pain  is  increased  by  defecation,  and  these  patients  are  uncom- 
fortable when  on  the  cars,  horseback-riding,  and,  in  fact,  at  all 
times  while  exercising.  Some  of  them  suffer  continuously, 
others  at  short  intervals,  and  still  others  have  only  one  or  two 
attacks  in  a  year.  The  pain  is  aching  in  character,  and  is 
located   over  the   lower   sacrum   and   coccyx.      Persons   long 


DISEASES,  INJURIES,  AND  TUMORS  OF  COCCYX  155 

affiicted  with  coccygodynia  are  extremely  nervous.  The  con- 
dition is  aggravated  by  coughing,  sneezing,  straining,  and  any- 
thing which  causes  pressure  on  the  coccyx,  or  produces  undue 
actiz'ity  of  the  muscles  attached  to  it. 

Diagnosis. — The  diagnosis  of  coccygodynia  is  easily  made 
by  the  physician  who  has  learned  to  be  on  the  lookout  for  it. 
Unfortunately  for  this  class  of  sufferers,  their  real  condition 
is  frequently  unrecognized,  and  they  are  treated  indefinitely 
for  some  other  complaint.  It  is  essential  to  examine  the  rec- 
tum thoroughly  in  every  case,  because  pains  simulating  those 
of  coccygodynia  are  frequently  induced  by  a  variety  of  diseases 
situated  in  this  organ.  The  urethra,  bladder,  vagina,  uterus, 
and  prostate  should  not  be  overlooked,  for  it  must  be  remem- 
bered that  the  seat  of  pain  is  not  always  at  the  seat  of  the  dis- 
ease. In  all  doubtful  cases  in  the  absence  of  disease  in  neighbor- 
ing organs,  with  a  history  of  injury  to  the  coccyx,  and  unbearable, 
dull,  aching  pains  in  this  region,  aggravated  by  pressure  over  the 
tip  of  the  bone,  a  diagnosis  of  coccygodynia  should,  be  made.  In 
order  to  detect  the  amount  of  pain  on  motion,  or  whether 
there  is  dislocation,  deformity,  or  fracture  of  the  coccyx,  the 
right  index  finger  should  be  passed  into  the  rectum  and  then 
backward  until  the  end  of  the  bone  is  located  and  seized  be- 
tween the  finger  and  the  thumb,  when  the  desired  manipula- 
tions of  the  bone  may  be  completed.  Coccygodynia  and 
neuralgia  of  the  rectum  are  frequently  mistaken  one  for  the 
other,  and  it  is  extremely  difficult  to  distinguish  between  them. 
In  the  former  pain  is  always  intensified  during  contraction  of 
the  muscles  attached  to  the  coccyx,  while  in  the  latter  such 
activity  does  not  seem  to  make  rhuch  difference. 

Prognosis. — The  prognosis  of  coccygod3mia  is  good  in  the 
majority  of  cases  when  it  is  properly  treated.  Much  better 
results  are  to  be  had  from  surgical  than  medical  treatment. 
By  means  of  the  former  a  speedy  cure  can  be  had,  while  by 
the  latter  recovery  is  usually  slow  and  frequently  unsatisfac- 
tory. 

Treatment. — Non-operative  measures  will  occasionally  effect 
a  permanent  cure;  but  in  most  cases  they  are  of  service  only 
because  they  offer  to  the  patient  temporary  relief.  Rest  is 
essential,  and  every  precaution  should  be  taken  to  prevent 
spasm    of    the    coccygeal    muscles,    thereby    reducing    pain    by 


156  DISEASES  OF  THE  RECTUM  AND  ANUS 

giving  rest  to  the  inflamed  joints  of  the  coccyx.  This  is  best 
accomphshed  by  hot  apphcations  or  counter-irritants  over  the 
sacro-coccygeal  region,  and  by  frequent  rectal  injections  of  hot 
water  or  oil,  the  latter  being  preferable  because  it  retains  heat 
the  longer.  Cold  is  not  desirable,  for  in  this  region  its  tend- 
ency is  to  excite  muscular  contraction.  Cauterization  with  the 
Paquelin  cautery  is  frequently  efficacious.  Nott  derived  some 
benefit  from  the  citrate  of  iron  in  5-grain  doses  given  three 
times  daily.  Bremer  condemns  operative  interference,  main- 
taining that  it  is  as  hopeless  as  neurectomy  in  facial  neuralgia. 
He  prefers  moderate  morphinism,  which,  to  the  author,  has 
greater  terrors  than  the  knife.  Whitehead  insists  upon  the 
value  of  first  correcting  the  disease  in  the  uterus,  bladder, 
urethra,  and  rectum.  Occasionally  much  benefit  is  to  be  de- 
rived from  the  prolonged  use  of  general  and  nerve-  tonics, 
such  as  iron,  arsenic,  etc.,  in  combination  with  remedies  that 
control  pain  and  encourage  sleep.  Where  palliative  measures 
fail  to  relieve  the  patient,  the  surgeon  should  then  be  called 
in.  A  surgical  operation  is  indicated  when  there  is  fracture, 
dislocation,  deformity,  necrosis,  or  periostitis  of  the  coccyx. 

Surgical  Procedures.  —  Two  operations  have  been  devised 
for  the  alleviation  of  painful  manifestations  about  the  coccyx 
(coccygodynia),  namely :  1.  Excision  of  all  or  a  part  of  the 
coccyx  (Nott's  operation).  2.  Separation  of  the  muscles  and 
ligaments  attached  to  the  coccyx  (Simpson's  operation). 

Nott's  Operation  of  Excision  (Coccygogeetomy). — The  opera- 
tion is  given  this  name  by  the  author  because,  in  his  opinion, 
Dr.  Nott  was  the  first  surgeon  to  remove  the  coccyx  for  the 
relief  of  coccygodynia.  The  steps  in  the  operation  are  as  fol- 
lows: 1.  A  dorsal  incision  from  two  to  three  inches  (5.08  to 
7.62  centimeters)  in  length  is  made  directly  over  the  coccyx. 
2.  The  bone  is  reached  by  dissections  and  freed  from  its  mus- 
cular and  ligamentous  attachments,  care  being  taken  not  to 
injure  the  bowel.  3.  The  coccyx  is  then  disarticulated  or  cut 
through  with  bone-forceps,  and  removed.  4.  The  wound  is 
closed  by  sutures  after  inserting  a  tube  or  gauze  drain. 

Simpson's  Operation  of  Tenotomy. — -This  operation  was  first 
performed  by  Prof.  J.  Y.  Simpson,  and  the  results  following  it 
were  very  satisfactory.  Of  late  the  operation  seems  to  have 
fallen  into  disrepute.  The  tecJmic  is  as  follows:  Introduce  a 
tenotomy-knife  through  a  small  incision  in  the  skin  near  the 


DISEASES,  INJURIES,  AND  TUMORS  OF  COCCYX  157 

tip  of  the  coccyx,  and  pass  it  upward  along  the  posterior  as- 
pect of  the  bone.  2.  Next  sever  all  tendinous  and  muscular 
attachments  from  both  sides,  underneath,  and  at  the  end  of 
the  coccj'x.  3.  Then  remove  the  knife  and  dress  the  wound. 
There  is  no  question  but  that  many  cases  of  coccygodynia  can 
be  speedily  relieved  by  this  operation,  because  rest  from  mus- 
cular activity  is  assured.  The  author  prefers  the  operation  of 
partial  or  complete  excision  of  the  coccyx  to  that  of  tenotomy, 
for  three  reasons : — 

1.  In  the  open  or  excision  method  any  large  vessel  severed 
■during  the  operation  can  be  immediately  secured. 

2.  In  the  tenotomy  operation  the  muscles  only  are  divided, 
and  the  inflamed  joint  is  left,  to  be  aggravated  by  walking  and 
sitting. 

3.  By  extirpation  the  offending  body — be  it  an  elongated, 
diseased,  fractured,  inflamed,  or  dislocated  bone — is  removed 
permanently. 

While  the  operation  of  excision  is  preferable,  the  original 
method  of  performing  it  has  been  greatly  improved  upon.  As 
done  in  the  past,  it  required  many  instruments,  was  bloody, 
consumed  considerable  time, — from  twenty  to  thirty  minutes, — 
and  a  drain  was  left  in  the  wound,  which  delayed  healing. 

Gant's  Operation  of  Coccygogectomy.  —  By  this  simple  pro- 
cedure all  or  a  part  of  the  coccyx  can  be  extirpated  in  short 
order.  The  operation  may  be  finished  in  from  three  to  five 
minutes.  It  is  bloodless,  and  the  only  requisites  for  its  per- 
formance are  a  specially-constructed  pair  of  strong,  blunt 
scissors  (Fig.  48);  a  large,  curved  needle;  and  two  or  three 
catgut  sutures. 

Teclinic. — 1.  With  the  thumb  and  finger  grasp  the  skin 
and  deeper  tissue  over  the  end  of  the  coccyx  so  as  to  make  a 
fold  at  right  angles  to  the  latter. 

2.  With  one  stroke  of  the  scissors  cut  through  these  struct- 
ures down  to  the  bone,  making  an  incision  one  inch  (2.54  centi- 
meters) long  and  parallel  with  the  coccyx. 

3.  Free  and  lift  the  end  of  the  coccyx  upward  with  the 
left  index  finger,  and,  by  rapid  cuts,  detach  all  ligaments  and 
muscles,  first  from  one  side,  then  the  other,  and  finally  from 
the  end  of  the  bone,  keeping  the  scissors  pointing  outward. 

4.  W^ithout  changing  the  position  of  the  finger,  place  the 


358 


DISEASES  OF  THE  RECTUM  AND  ANUS 


scissors  at  a  right  angle  as  to  the  os  coccyx-  (Fig.  49)  and  dis- 
articulate or  divide  it,  as  the  case  requires. 

5.  Close  the  wound  with  two  or  three  interrupted  catgut 
sutures,  and  dress  it  with  sterile  gauze  held  in  place  by  adhe- 
sive straps. 

The  author  has  performed  this  operation  for  the  relief  of 
pathologic  conditions  of  the  coccyx  35  times  without  an  unpleas- 
ant complication  or  sequel  except  in  3  cases.  In  1  a  fistula  re- 
mained after  the  operation  and  refused  to  heal  under  local  treat- 
ment. Finally  a  portion  of  a  silk-worm-gut  suture  was  dis- 
charged, and  the  patient  promptly  recovered.  In  another,  where 
the  wound  was  dressed  with  iodoform  gauze,  a  dermatitis  ensued, 
which  was  followed  by  sloughing  of  the  tissues  over  the  end  of 
the  sacrum  until  the  bone  was  bare.     It  required  six  months  to 


Fig.   48. — Gant's   Coccygeal  Scissors.      They  Are  Very   Strong,   and  Cut  bkin, 
Muscles,   Tendons,    and   Bone   Equally   WelL 

heal  the  wound;  during  this  time  the  patient  suffered  intensely. 
In  the  third  case  plain  catgut  was  used;  on  the  fourth  day  the 
patient  went  to  the  closet  without  permission,  and  while  there 
tore  the  wound  open,  thus  delaying  his  recovery  several  days. 
Occasionally,  when  proper  aseptic  precautions  have  not  been 
observed,  stitch  abscesses  occur.  The  author  has  used  wire,  silk,, 
silk-worm  gut,  chromicized  and  plain  catgut  for  closing  the 
wounds  after  this  operation,  and  he  very  much  prefers  the  latter. 
The  advantages  claimed  for  this  method  of  excising  the  coccyx 
are  that  it  is  bloodless,  painless,  can  be  performed  quickly  (in 
from  two  to  three  minutes),  and  with  two  instruments  (scissors 
and  needle)  ;  primary  union  can  be  obtained  along  the  entire  cut 
because  drainage  is  not  necessary ;  unpleasant  sequels  have  rarely 
been  known  to  follow  it;  and,  further,  because  the  patients  are 
not  required  to  remain  in  the  hospital  more  than  a  week  or  ten 
days. 


DISEASES,  INJURIES,  AND  TUMORS  OF  COCCYX 


159 


FRACTURES,   DISLOCATIONS,   INJURIES,   AND   NECROSIS 
OF  THE   COCCYX 

The  OS  coccyx,  like  other  bones  of  the  body,  is  frequently 
the  seat  of  injury.  Fractures  and  dislocations  of  the  coccyx 
are  not  uncommon,  and  are  usually  caused  by  a  blow,  kick,  fall, 
or  the  passage  of  the  child's  head  during  labor. 

Other  injuries — gunshot,  stab,  and  extensive  lacerated 
wounds — are  occasionally  met  with  in  this  region.  The  author 
treated  a  thief  who  had  been  shot  in  the  anus  while  trying  to 
escape;    the  ball  came  out  near  the  sacro-coccygeal  articula- 


Fig.  49.— Gant's  Operation  of  Coccygogectomy. 


tion,  carrying  part  of  the  bone  with  it.  Bellamy  treated  a  boy 
who  was  accidentally  shot.  The  coccyx  was  torn  off,  and  an 
opening  the  size  of  an  orange  was  made  in  the  rectum,  through 
which  gas  and  feces  escaped,  and  fragments  of  the  bone  were 
plainly  visible.  Numerous  cases  of  injury  to  the  coccyx,  caused 
by  gunshot  and  bayonet  wounds,  are  to  be  found  in  the  medical 
and  surgical  history  of  the  War  of  the  Rebellion. 

Symptoms  and  Diagnosis.  —  Fractures,  dislocations,  and  in- 
juries to  the  coccyx  cause  a  heavy,  dull,  aching  pain  in  this 
region,  which  is  made  worse  by  contraction  of  the  attached 
muscles,  walking,   and  sitting.     These   sufiferers   are   relieved 


160  DISEASES  OF  THE  RECTUM  AND  ANUS 

when  lying  upon  the  abdomen.  Pressure  over  the  end  of  the 
bone  causes  agonizing  pain,  both  in  the  region  of  the  coccyx 
and  up  the  back  and  down  the  Hmbs.  Suffering  is  intense 
during  and  for  a  short  while  after  defecation.  Hemorrhage  is 
seldom  encountered,  except  in  cases  where  the  wound  is  ex- 
tensive and  involves  the  hemorrhoidal  vessels.  Where  the 
rectum  has  been  punctured,  both  gas  and  fecal  matter  escape, 
producing  an  offensive  odor.  Fractures  and  dislocations  im- 
properly treated  fre(juently  result  in  enlargement,  ankylosis, 
and  displacement  of  the  coccyx,  which,  in  time,  cause  coc- 
cygodynia  or  neuralgia. 

Necrosis. — Necrosis  of  the  coccyx,  ending  in  abscess  and 
fistula,  is  a  frequent  sequel  of  injury  to  this  bone.  This  con- 
dition may  also  be  the  result  of  syphilis,  tuberculosis,  and  malig- 
nant diseases.  In  such  cases  the  amount  of  bone  destroyed  is 
considerable.     Again,  it  may  be  caused  by  any  disease  or  in- 


Fig.  50. — Rubber  Glove,  Especially  Valuable  in  Rectal  Operations. 

jury  which  destroys  the  periosteal  covering.  The  immediate 
manifestations  of  dead  bone  in  this  region  do  not  differ  from 
a  similar  condition  in  other  parts.  There  is  a  fistulous  opening, 
a  discharge  of  pus,  and  the  grating  sound  produced  by  the 
probe  coming  in  contact  with  eroded  bone.  The  openings  may 
be  single  or  multiple,  and  when  they  become  stopped  up  a  chill, 
rise  of  temperature,  and  increased  pain  follow  shortly,  caused 
by  the  formation  of  an  abscess. 

Diagnosis.  —  Fractures  and  dislocations  are  easily  recog- 
nized by  introducing  the  finger  into  the  bowel,  when  the  coc- 
cyx may  be  seized  and  examined ;  flesh  wounds  over  the  bone 
by  their  presence,  and  necrosis  by  the  finding  of  dead  bone 
by  aid  of  the  probe.  A  clear  history  of  the  case  goes  far 
toward  establishing  the  diagnosis  in  doubtful  cases. 

Treatment.  —  Extensive  wounds  involving  both  the  soft 
parts  and  bony  structures  demand  prompt  and  careful  atten- 
tion. When  the  parts  are  lacerated  the  edges  of  the  wound 
should  be  trimmed,  all  fragments  of  bone  removed,  and  the 


DISEASES,  INJURIES,  AND  TUMORS  OF  COCCYX  161 

wound  closed  with  catgut.  Drainage  is  unnecessary,  unless 
there  is  danger  of  leakage  from  the  rectum.  When  the  coccyx 
is  fractured  or  badly  displaced  better  results  are  to  be  had  in 
most  instances  from  partial  or  complete  resection.  It  is  an 
extremely  difficult  matter  to  retain  it  in  place  and  to  secure 
complete  rest  by  splints,  sutures,  or  other  appliances.  Skey 
attempted  to  retain  the  coccyx  in  position  in  a  case  of  disloca- 
tion by  placing  a  wire  spring  in  the  rectum.  This  broke,  and 
he  then  anchored  the  bone  to  a  wooden  splint  on  the  back  by 
means  of  a  silk  thread.  This  did  not  entirely  relieve  the  pain, 
but  the  patient  was  discharged  twenty  days  later  much  im- 
proved. Some  surgeons  tampon  the  rectum,  but  the  results 
have  not  been  satisfactory,  for  the  reason  that  the  tampon  does 
not  retain  its  position,  and,  in  addition,  pain  is  greatly  intensi- 
fied by  retention  of  gases.  The  author  obtained  a  good  result 
in  one  case  by  placing  a  finger  in  the  bowel  and  pressing  the 
bone  outward.  A  needle  carrying  chromicized  catgut  was 
then  passed  through  the  skin  down  to  the  bone,  catching  the 
tendinous  attachments,  and  brought  out  near  the  point  of  en- 
trance, where  the  suture  was  tied  across  a  small  gauze  pad. 
Pain  was  relieved  immediately,  and  the  patient  was  discharged 
in  two  weeks  feeling  perfectly  well.  In  exceptional  cases 
properly-adjusted  adhesive  straps  give  a  sense  of  support  to 
the  parts  and  diminish  pain.  When  surgical  aid  is  declined, 
complete  rest  in  bed,  a  semisolid  diet,  and  hot  apphcations  over 
the  ano-coccygeal  region  will  do  much  toward  making  the 
sufferer  comfortable.  If  used  at  all,  opiates  should  be  discon- 
tinued after  the  first  few  days.  Necrosed  bone  should  be  re- 
moved. 

SACRO=COCCYGEAL  TUMORS   AND   CYSTS 

Braune,  in  1862-64,  published  an  analysis  of  fifty  cases  of 
tumors  involving  the  sacrum  and  coccyx,  embracing  practically 
all  that  had  been  published  up  to  that  time.  He  was  the  first 
surgeon  who  attempted  to  classify  these  neoplasms,  and  to 
point  out  the  various  methods  used  to  destroy  them.  Holmes, 
in  a  practical  paper  written  in  1867,  called  attention  to  this  class 
of  tumors  and  the  satisfactory  results  to  be  had  from  their 
total  extirpation. 

Tumors  of  this   region,   except  dermoid  cysts   described 

elsewhere   (page  491),  are  of  rare  occurrence,   and  are  met 

11 


163 


DISEASES  OF  THE  RECTUM  AND  ANUS 


with  more  frequently  by  the  obstetrician  than  the  surgeon,  be- 
cause they  are  congenital  and  noticeable  at  birth.  They  belong 
plainly  in  the  domain  of  rectal  surgery,  for  the  reason  that 
they  displace  the  rectum  and  anus  (see  Dr.  Lord's  case.  Figs. 
51  and  52),  interfering  with  the  performance  of  their  functions. 
Braune  divided  them  into  the  following  varieties: — 

1.  Coccygeal  tumors  in  the  proper  sense. 

2.  Sacral  hygromata. 

3.  Tail-like  formations  and  lipomatous  appendages. 

4.  Tumors  in  the  adult,  the  congenital  nature  of  which  is 
not  clearly  proven. 

Holmes    suggests    the    following    arrangement    of    these 


Fig.  51. — Sacro-coccygeal  Tumor  (Front  View). 


growths:  (a)  tumors  assuming  the  forms  of  supernumerary 
limbs,  the  result  of  double  fetation ;  (b)  tumors  with  fibro-fatty 
(Hpomata)  constituents  where  congenital  duration  is  not  ap- 
parent; (c)  congenital  tumors  which  enter  the  pelvis,  not  of 
fetal  origin. 

In  recent  years  many  cases  of  sacro-coccygeal  tumors  have 
been  reported,  some  of  which  do  not  seem  to  fall  within  the 
classifications  of  either  Braune  or  Holmes.  Because  of  their 
variety,  difference  in  shape,  consistence,  contents,  and  eti- 
ology, a  grouping  of  these  neoplasms  is  extremely  difficult. 
Again,  it  is  frequently  impossible  to  make  a  positive  diagnosis 
in  these  cases  except  by  operation  or  autopsy.    For  the  reasons 


DISEASES,  INJURIES,  AND  TUMORS  OF  COCCYX 


16'i 


named,  the  author  will  not  attempt  a  rearrangement  of  these 
tumors,  but  will  simply  point  out  their  principal  manifestations, 
which,  after  all,  are  of  most  importance  to  the  surgeon. 

Neoplasms  of  the  coccyx  may  be  attached  by  a  broad  base 
or  narrow  pedicle,  and  vary  in  size  from  a  cherry  to  that  of  a 
child's  head  (Figs.  51  and  52).  They  may  be  globular, 
oblong,  and  irregular  in  shape;  soHd,  semisoHd,  or  soft;  and, 
when  cystic,  unilocular  or  multilocular,  with  fibrous  partitions. 
Most  tumors  of  this  region  are  congenital,  the  exceptions  being 
lipomata  and  supernumerary  limbs  not  visible  at  birth. 

Contents. — Nearly  all  of  the  various  structures  of  the  body 


Fig.  52. — Sacro-coccygeal  Tumor  (Rear  View). 


have  been  found  in  the  different  forms  of  sacro-coccygeal  tu- 
mors and  cysts:  Fluids, — spinal  (spina  bifida),  albuminous, 
creamy,  red,  yellow,  straw,  or  brown  in  color, — alone  or  to- 
gether with  cheesy  matter,  bones  (short  and  long),  hair,  teeth, 
muscular  fiber,  brain-substance,  blood,  cartilage,  fat,  mucus, 
and  the  bones  of  the  sternum.  Again,  various  appendages  may 
have  their  origin  in  these  tumors.  Supernumerary  fingers,  toes, 
hands,  feet,  arms,  legs,  and  fleshy  projections,  a  tail,  and  penis 
have  all  been  seen  projecting  from  growths  taking  their  origin 
in  the  sacro-coccygeal  region.  In  most  instances  congenital 
sacro-coccygeal  tumors  are  of  sufficient  size  at  birth  to  attract 
the  attention  of  the  physician  in  attendance.  Pithas's  case, 
however,  is  an  exception  to  this  rule..     He  amputated  a  third 


164  DISEASES  OF  THE  RECTUM  AND  ANUS 

leg  attached  to  the  coccyx  of  a  young  woman  20  years  old. 
In  this  case  there  was  only  a  slight  enlargement  of  the  coccyx 
at  birth.  Senftleben  removed  a  small  hand  attached  to  the 
caudal  bones,  and  Mason  extirpated  a  lymphadenoma  the  size 
of  a  fetal  head.  Hutchinson  removed  a  tumor  containing  a 
sternum  and  brain-substance;  but  one  of  the  most  interesting 
cases  of  coccygeal  tumor  is  that  of  Chebbs,  in  which  a  fleshy 
mass,  two  inches  (5  centimeters)  long  and  a  half-inch  (1.27 
centimeters)  in  diameter,  projected  from  the  spine,  in  the  end 
of  which  was  an  orifice  connecting  with  a  canal  running  the 
entire  length  of  the  tumor.  It  looked  exactly  like  the  penis  of 
a  boy  six  years  old.  The  daily  press  came  out  with  big  head- 
lines telling  all  about  the  boy  with  a  tail.  As  lack  of  space 
forbids  relation  of  examples  of  the  different  types  of  sacro- 
coccygeal tumors,  the  attention  of  the  reader  is  next  invited 
to  the  symptoms  produced  by  these  neoplasms. 

Symptoms. — Displacement  of  both  the  rectum  and  the  anus 
always  takes  place.  Usually  they  are  pushed  forward  with  the 
vagina  and  vulva;  in  exceptional  cases  the  displacement  is  to 
the  right  or  left  of  the  median  line.  The  coccyx  and  lower 
sacrum  are  dislocated  backward,  and  are  readily  noticeable 
through  the  integument.  The  skin  may  be  natural,  or  bluish, 
or  become  ulcerated  from  pressure  when  there  is  great  ten- 
sion. Prolapse  of  the  rectum  and  uterus  and  eversion  of  the 
anus  frequently  occur  when  the  tumors  expand  downward. 
Constipation  is  marked,  and  fissures,  hemorrhoids,  and  ulcera- 
tion are  usually  present  as  the  result  of  pressure  and  interfer- 
ence with  the  circulation.  Necrosis,  abscess,  and  fistula  of  the 
sacrum  and  coccyx  may  result  from  the  same  cause.  Owing  to 
the  attachment  of  these  tumors  to  the  rectum  and  bladder,  and 
pressure  upon  the  urethra,  dragging-down  pains  are  felt  in  the 
rectum,  and  the  urine  is  voided  with  great  difliculty.  These 
patients  suffer  from  neuralgic  pains  over  the  coccyx,  up  the 
back,  and  down  the  limbs.  Children  afflicted  with  sacro-coc- 
cygeal  tumors  communicating  with  the  spinal  cord  are  subject 
to  convulsions,  especially  where  the  contents  are  evacuated 
rapidly.  When  located  high  up  in  the  pelvis  of  an  infant,  such 
a  tumor  may  be  unrecognized,  and  may  produce  partial  or  com- 
plete intestinal  obstruction. 

Diagnosis.  —  The  diagnosis  of  sacro-coccygeal  tumors  is 
easy  in  most  cases,  because  of  their  size  and  location.     In  fact, 


DISEASES,  INJURIES,  AND  TUMOES  OF  COCCYX  165 

all  congenital  tumors  situated  posterior  to  the  anus  and  rec- 
tum at  the  end  of  the  spine  belong  to  this  class.  It  is  a  more 
difficult  matter,  however,  to  determine  their  exact  nature  and 
contents.  When  soft,  fluctuation  and  impulse  on  coughing  are 
obtained.  ]\Iuch  information  as  to  the  size,  consistency,  and 
attachment  of  the  growth  can  be  gained  by  rectal  and  vaginal 
examination.  Occasionahy  these  tumors  are  transparent,  but 
more  often  they  are  filled  with  thick,  colored  fluid,  the  nature 
of  which  is  revealed  by  aspiration.  When  spinal  origin 
is  suspected,  considerable  fluid  should  be  removed,  and,  if  the 
surmise  is  correct,  the  operation  will  very  probably  be  followed 
by  convulsions.  Tumors  situated  directly  in  the  median  line 
are  nearly  always  spina  bifida;  but,  if  there  is  still  any  doubt, 
the  fluid  should  be  examined  under  the  microscope.  If  chemic 
examination  shows  the  presence  of  sugar,  this  points  to  the 
spinal  origin-  of  the  neoplasm.  Tumors  containing  super- 
numerary limbs  are  easily  recognized,  and  in  such  cases  a  diag- 
nosis of  double  fetation  is  justifiable. 

Prognosis. — The  prognosis  depends  largely  upon  the  nature 
of  the  growth  and  the  methods  resorted  to  for  its  destruction. 
There  is  necessarily  a  large  mortality  in  these  cases,  because 
of  the  magnitude  of  the  operation  required  for  their  removal, 
and,  further,  because  the  victims  are  usually  infants  possessing 
little  vitality. 

Treatment. —  Non-operative  measures  have  no  place  in  the 
treatment  of  sacro-coccygeal  tumors.  Iodine  and  carbolic  acid 
have  been  injected  into  them,  but  with  the  single  exception  of 
Strassman's  case,  which  was  cured  by  use  of  the  former,  they 
have  failed  to  benefit  the  patient.  The  following  are  the  pro- 
cedures which  surgeons  have  resorted  to  in  their  efforts  to  re- 
move or  destroy  these  tumors :  (a)  tapping,  (b)  partial  resection 
and  ligature,  (c)  ligature,  and  (d)  complete  extirpation. 

Tapping. — This  rarely  has  any  curative  effect,  and  requires 
to  be  repeated  again  and  again.  When  the  tumor  has  spinal 
connections,  the  abstraction  of  fluid  is  followed  by  convulsions, 
sometimes  meningitis  and  death. 

Partial  Resection. — This  should  be  practiced  ojily  in  cases 
where  total  extirpation  is  attempted  and  found  impracticable 
because  of  the  deep  or  extensive  attachments  of  the  growth. 
In  such  cases  as  much  as  possible  of  the  tumor  should  be  ligated, 
and  removed  after  the  ligature  has  been  adjusted. 


166  DISEASES  OF  THE  RECTUM  AND  ANUS 

Ligature. — Ligation  is  indicated  only  in  cases  where  the 
tumor  is  small  and  pedunculated.  It  is  a  mistake  to  ligate  a 
large  tumor  with  the  expectation  that  it  will  slough  off.  The 
principal  objections  to  this  operation  are  that  the  ligature  is 
not,  as  a  rule,  applied  sufficiently  high  to  include  all  the  sac, 
and  does  not  always  cut  its  way  through,  thus  leaving  the  tumor 
partially  severed  from  its  attachment. 

Complete  Extirpation. — This  is  the  most  desirable  method 
of  getting  rid  of  sacro-coccygeal  tumors,  unless  there  are  spinal 
attachments,  when  they  are  best  let  alone.  At  least  one  such 
tumor,  however,  has  been  successfully  excised.  The  statistics 
of  Braune,  Holmes,  and  others  show  that  complete  removal 
of  these  growths  gives  the  best  results,  and  is  followed  by  a 
much  lower  mortahty  than  either  of  the  methods  previously 
described. 

The  technic  of  the  operation  is  as  follows :  A  free  incision 
is  made  over  the  tumor,  and  the  latter  is  carefully  dissected 
out,  separating  it  from  neighboring  structures  with  the  finger 
or  blunt  scissors.  When  of  a  cystic  nature,  every  precaution 
should  be  taken  not  to  puncture  the  retaining  wall,  and  when 
attached  by  a  pedicle  it  should  be  traced  upward  to  its  origin, 
though  it  passes  high  up  into  the  pelvis,  then  extirpated  com- 
pletely. The  wound  in  the  peritoneum  and  the  external  in- 
cision should  be  closed  with  catgut;  if  there  is  great  tension 
on  the  external  wound,  silk  sutures  are  better.  Primary  union 
will  follow.  On  the  other  hand,  where  a  portion  of  a  cyst  or 
tumor  is  left,  suppuration  and  recurrence  of  the  growth  are 
to  be  expected. 

Supernumerary  limbs  which  project  from  a  tumor  in  the 
coccygeal  region  should  be  amputated  in  the  usual  way  or 
resected  as  circumstances  demand.  Hands,  feet,  and  legs  have 
been  successfully  removed  from  these  parts  in  both  children 
and  adults  after  they  had  attained  considerable  size.  In  three 
of  the  cases  reported  by  Braune  it  was  necessary  to  saw 
through  the  bony  stalk  which  extended  very  high  in  the  pelvis. 

SYPHILIS  AND  TUBERCULOSIS  OF  THE  COCCYX 

Both  syphilis  and  tuberculosis  are  occasionally  met  with 
in  the  sacro-coccygeal  region.  They  attack  the  periosteum, 
bone,  and  sometimes  the  overlying  structures,  causing  necro- 
sis, abscess,  and  fistula. 


DISEASES,  INJURIES,  AND  TUMORS  OF  COCCYX  167 

Treatment. — These  patients  require  good  surroundings, 
tonic,  antisyphilitic,  and  antitubercular  treatment.  Dead  bone 
should  be  removed,  the  affected  parts  curetted,  and  afterward 
stimulated  by  applications  known  to  encourage  granulation. 

This  chapter  will  be  closed  by  appending  the  following 
table  of  cases  of  disease,  injury,  and  tumors  of  the  coccyx 
treated  by  the  author.  Such  an  analysis  may  be  of  service  to 
physicians  and  surgeons  interested  in  this  class  of  affections. 


168 


DISEASES  OF  THE  EECTUM  AND  ANUS 


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172  DISEASES  OF  THE  RECTUM  AND  ANUS 

ILLUSTRATIVE  CASE 

Case  III.     Entire  Absence  of  the  Coccyx  in  an  Adult   (Congenital). — 

Male,  40  years  old,  referred  to  me  by  Dr.  B.,  of  Kansas  City,  Kan.,  to  be 
operated  on  for  fissure.  During  and  after  stool  he  complained  of  considerable 
pain,  which  frequently  extended  up  the  back.  At  night  he  was  annoyed  by 
a  persistent  pruritus,  evidently  caused  by  a  discharge  which  kept  the  anus 
moist.  Separation  of  the  buttocks  revealed  a  tight  sphincter  and  a  sharply- 
defined  fissure,  half  an  inch  (1.27  centimeters)  in  length,  situated  posteriorly, 
at  the  anal  margin.  This  was  cocainized  and  the  finger  passed  into  the 
rectum  in  order  to  determine  if  there  was  any  complication.  The  bowel  ap- 
peared healthy,  but  the  coccyx  could  not  be  located.  Thorough  examination 
within  and  outside  the  bowel  by  two  other  physicians  and  myself  satisfied 
us  that  we  had  a  case  of  congenital  absence  of  the  coccyx.  The  sacrum  ter- 
minated in  a  blunt  extremity,  two  inches  wide,  readily  noticeable  through  the 
skin.  From  it  to  the  anus  the  tissues  drooped  inward,  leaving  a  concavity 
large  enough  to  hold  a  goose-egg.  The  finger  in  the  bowel  was  easily  felt  by 
palpation  of  the  coccygeal  region.  This  man  had  never  suffered  any  incon- 
venience from  his  bladder  or  rectum  until  six  weeks  before  he  came  under  the 
author's  observation.  The  sphincter  was  divulsed,  the  fissure  incised,  and  he 
made  an  uninterrupted  recovery. 


LITERATURE  ON  THE  DISEASES,  INJURIES,  AND  TUMORS 
OF  THE  COCCYX 


Abnokmalities  of  the  Coccyx 
Darrah:    Boston  Med.  and  Surg.  Journal,  vol.  xxviii,  p.  36,  1893. 
Dunn:    GMy's  Eosp.  Reports,  London,  vol.  xxx,  p.  191,  1889. 
Evans:    PMla.  Med.  Times,  vol.  xviii,  p.  35,  1887-88. 
Farr:    Guy's  Eosp.  Gaz.,  London,  vol.  iii,  p.  173,  1889. 
Hale:    Eomeop.  Jour,  of  Ohstet.,  N.  Y.,  vol.  x,  pp.  9,  124,  197,  308,  1888. 
Hershey:    Boston  Med.  and  Surg.  Jour.,  vol.  liv,  p.  516,  1856. 
Imlach:    Brit.  Qynec.  Jour.,  London,  vol.  i,  p.  319,  1885. 
Macdonald:    Edinburgh  Med.  Jour.,  vol.  xxxi,  p.  318,  1885. 
Odell:    Lancet,  London,  p.  1088,  1887. 
Post:    N.  T.  Med.  Jour.,  vol.  xxx,  p.  517,  1879. 
Sayre:    Med.  Record,  N.  Y.,  vol.  ix,  p.  242,  1874. 

Summers:    Amer.  Jour.  Med.  Sciences,  N.  S.,  xix.     Philadelphia,  1850. 
Whitehead:    London  Lancet,  vol.  ii,  p.  112,  1886. 

Coccygeal  Body  (Luschka's  Gland) 
Banks:    Glasgow  Med.  Jour.,  3,  s.  ii,  p.  1,  1867. 
Jakobsson :    Upsal.  Ldkaref.  Forh.,  n.  f .,  iii,  p.  324,  1897  98. 
Krause:    Ztschrf.  f.  rat.  Med.,  1866. 
Luschka:     "Die  Steissdriise,"  etc.     Leipzig,  1860. 
Macallister:    Brit.  Med.  Jour.,  vol.  i,  p.  125,  1868. 


DISEASES,  INJURIES,  AND  TUMORS  OF  COCCYX  173 

Macdonald:    Glasgow  Med.  Jour.,  3,  s.  ii,  pp.  171-3,  1867-68. 
Senftleben:    Deutsche  Elinik,  p.  174,  )865. 

COCCYGODYNIA 

Banvell:    Med.  Weeklij,  vol.  ii,  p.  149,  Pas.,  1894. 

Borst:    '"Die  angeb.  Geschwiilst  d.  sacr.  Reg.,"  Centr.  f.  allg.  Path.  u.  path. 

Anat.,  Jena,  ix,  pp.  449-501,  1898. 
Bremer:    Med.  Record,  vol.  1,  p.  154.    New  York,  1896. 
Carriere:    "La  sacro-coccygod.,"  Echo  vied,  du  nord,  Lille,  ii,  p.  592,  1898. 
Cooper  and  Edwards:    "Diseases  of  the  Rectum  and  Anus,"  p.  315,  1892, 
Nott:    New  Orleans  Med.  Jour.,  vol.  i,  1844. 

Amer.  Jour.  OI)s.,  p.  243,  1869. 
Peyer:    Ceutr.  f.  klinlsh.  Med.,  vol.  ix,  p.  659,  1888. 

Von  Franque:    "Ueber  Coccygodyn.,"  Memorabilien,  Heilb.,  viii,  p.  105,  1862. 
Von  Scanzoni:    "Ueber  Coccygod.,"  Wurzl).  md.  Ztsch.,  ii,  p.  320,  1861. 
Worms:    "Coccygod.,"  "Diction,  encyclop.  d.  med.,"  Pt.  XVIII,  p.  174,  1876. 

Fractures  and  Dislocations  of  the  Coccyx 
Bailey:    "Fract.  of  Coccyx,"  Jour.  Med.  Soc.  Ark.,  vol.  iv,  p.  108,  1893-94. 
Bellamy:    North  Conn.  Med.  Jour.,  vol.  i,  p.  151,  1878. 
Betz:    "Steissbeinbriiche,"  etc.,  Memorabil.,  Heilb.,  x,  p.  58,  1865. 
Blackwood:    "Necess.  of  Accur.  Diag.,"  Proc.  Phil  a.  Med.  Soc,  vol.  ii,  p.  56, 

1880. 
Bonnafaut:    "Deux  obsv.  de  lux  du  coccyx,"  Union  Med.,  2,  s.  i,  p.  136.     Paris, 

1859. 
Cleveland:    "Fract.  of  Coccyx,"  N.  J.  Med.  Rep.,  vol.  vi,  p.  171,  1853. 
Gant:    Langsdale's  Lancet,  vol.  i,  p.  306,  1896. 

Gervay:    "Disloc.  of  Coccyx,"  St.  Louis  Med.  Cour.,  vol.  xx,  p.  544,  1888. 
Jackson:    "Fract.  of  Coccyx,"  Langsdale's  Lancet,  vol.  i,  p.  209,  1896. 
Jolly:    "Fracture  and  Passage  of  Segment  of  Bone,"  N.  Y.  Med.  Rec,  vol.  xxxii, 

p.  672,  1887. 
Sky:    Lancet,  London,  vol.  ii,  p.  326,  1861. 
Warren:    "Inj.  of  Coccyx,"  "Surg.  Obs.,"  p.  593,  1867. 

Sacro-coccygeal  Tumors 
Borst:     "Die  angeb.  Geschwiilst  d.  sacr.  Reg.,"  Centr.  f.  allg.  Path.  u.  path. 

Anat.,  vol.  ix,  p.  449.    Jena,  1898. 
Bowlby:    "Coccyg.  Tumors,"  Brit.  Med.  Jour.,  vol.  i,  p.  663,  1890. 
Braune:    "Die  Doppeltbild.  u.  Geschw.  d.  Kreuzbein.  Geg."     Leipzig,  1862. 

"Ang.  Steissbeingeschw.  Monatssch.  f.  Geburtsh.  u.  Frauenkh.,"  voL 

xxiv,  1864. 
Buck:    "Coccyg.  Cysts,"  N.  Y.  Med.  Rec,  vol.  i,  p.  96,  1866. 
Cabot:    "Sacral  Teratom.,"  Boston  Med.  and  Surg.  Jour.,  vol.  xcviii,  p.  112, 

1878. 
Chibb:    Med.  Times,  London,  vol.  xvi,  p.  274,  1847. 
De  Rothschild:    Bull.  Soc.  d'Obst.  de  Paris,  vol.  ii,  pp.  71-76,  1899. 
Elis:    Boston  Med.  and  Surg.  Jour.,  vol.  Ixxii,  p.  417,  1865. 
Favel  and  Jackson:    Lancet,  London,  vol.  i,  p.  843,  1885. 
Holmes:    Brit.  Med.  Jour.,  p.  315,  1867. 


174  DISEASES  OF  THE  RECTUM  AND  ANUS 

Johnson:    London  Lancet,  vol.  ii,  p.  35,  1857. 
Lawrence:    London  Lancet,  vol.  i,  p.  313,  1861. 
Lepelletries :    London  Lancet,  4-11-158,  1833. 
Mason:    Trans.  Path.  Soc,  London,  vol.  xxv,  p.  194,  1874-75. 
McCarthy:    London  Lancet,  vol,  i,  p.  920,  1888. 
McDowell:    Med.  Press  and  Circ.,  vol.  xxxiii,  p.  271.    London,  1882. 
Owen:    Trans.  Path.  Sac,  London,  vol.  xxxi,  pp.  425-7,  1887-88. 
Shattuck:    Trans.  Path.  Soc,  London,  vol.  xxiv,  p.  197,  1880-81. 
Stanley:    Med.  and  Chir.  Trans.,  London,  vol.  xxiv,  1841. 

Wodynski:    "Angio-sarcom.  cyst.,"  Jahr.  d.  Bosn.  Herzeg.,  Landespil  in  Sarjemo, 
1894-96.    Wien,  1898,  pp.  787-90. 


CHAPTER  XI 

VENEREAL  DISEASES 

The  expression,  "venereal  disease,"  is  used  to  designate 
any  ailment  or  injury  resulting  either  directly  or  indirectly 
from  any  form  of  sexual  intercourse.  For  this  reason  it  has 
been  chosen  as  a  caption  for  this  chapter,  in  which  diseases 
of  this  type  as  encountered  in  the  ano-rectal  region  will  be 
described. 

This  is  a  class  of  affections  which  are  met  with  by  the 
proctologist  more  frequently  than  is  generally  suspected  by 
the  profession  at  large.  Yet,  when  the  close  proximity  of  the 
anus  and  genitals,  and  the  great  perversity  of  the  sensual 
mind  are  considered,  this  is  not  so  surprising. 

GONORRHEA   (CLAP) 

Gonorrhea  or,  more  correctly,  hlennorrhea  of  the  rectum 
is  a  proctitis  caused  by  infection  with  the  goiwcoccits,^  first 
described  by  Neisser,  in  1879,  and  isolated  by  Bumm  in  1886. 

Etiology.' — Gonorrhea  of  the  rectum  is  comparatively  rare, 
and,  as  already  stated,  is  caused  by  a  specific  micro-organism, 
the  diplococcus  gonorrhoeae.  The  disease  is  more  frequently 
met  with   in  women   than   men,    and   for   the   following  two 


1  The  gonococcus  is  now  quite  generally  recognized  as  the  specific  cause  of  gonor- 
rhea. It  is  constantly  and  exclusively  found  in  gonorrhea  and  in  identically  similar 
processes.  A  peculiarity  of  the  gonococci — a  feature  which  does  not,  however,  belong 
to  them  alone — is  that  the  majority  of  them  enter  the  bodies  of  the  pus-cells,  where  they 
multiply  in  such  a  manner  that  they  appear  wholly  to  fill  up  the  cell-body  and  partially 
or  completely  obscure  the  nucleus.  They  but  rarely  enter  the  squamous  epithelia,  and 
more  rarely  Invade  the  cylindric  epithelial  cells.  The  cocci  almost  always  appear  in 
smaller  or  larger  groups,  the  individuals  being  mostly  united  in  pairs  (resembling  a 
coffee-bean),  icith  their  flattened  surfaces  in  apposition.  Now  and  then  are  seen  four  in 
close  contact,  which  arrangement  is  produced  by  fission  in  two  directions  of  space. 
The  line  of  division  between  each  pair  of  cocci  is  quite  broad  and  always  recognizable. 

Method:  With  the  edge  of  a  glass  slide  take  up  a  portion  of  the  gonorrheal  dis- 
charge, and,  by  a  single  stroke,  quickly  spread  it  out  into  a  thin  layer  upon  the  surface 
of  another  slide.  When  dry,  stain  for  a  few  seconds  with  cold  Loeffler's  methylene-blue 
solution  (see  page  68),  wash  in  water,  dry,  and  examine  in  cedar-oil  with  V12  oil- 
immersion  lens.  As  the  gonococci  are  decolorized  by  Gram's  method  of  staining,  this 
procedure  is  frequently  called  into  use  where  any  doubt  as  to  the  exact  nature  of  the 
cocci  exists.  Gram's  method  is  particularly  valuable  when  the  characteristic  grouping 
of  the  cocci  within  the  pus-cells  is  absent.  In  Gram's  method  the  Koch-Ehrlich  solu- 
tion is  used.     This  solution  is  prepared  as  follows: — 

(175) 


176  DISEASES  OF  THE  KECTUM  AND  ANUS 

reasons :  (a)  in  infection  of  the  vagina,  urethra,  or  uterus 
the  discharge  dribbles  over  the  anus  and  attacks  the  anal  mu- 
cosa ;  (b)  when  the  urethra  of  the  male  is  infected  primarily 
the  anus  of  the  woman  may  become  infected  during  coitus. 

Gonorrheal  proctitis  occurs  more  often  in  boys  and  young 
men  than  in  older  individuals  of  the  same  sex.  When  men 
are  affected  with  it  the  specific  micro-organisms  have  usually 
been  deposited  in  the  rectum  during  unnatural  intercourse 
(pederasty).  The  malady  is  frequently  found  in  men  who 
spend  considerable  time  where  there  are  no  women,  as  at  sea 
or  in  prison.  The  author  treated  a  girl  baby,  10  weeks  old, 
suffering  from  this  complaint  contracted  in  some  way  from  her 
nurse ;  also  a  physician  who  infected  himself  during  treatment 
for  gonorrheal  urethritis. 

The  author  does  not  believe  that  the  mucous  membrane 
of  the  anal  verge  is  as  susceptible  to  invasion  by  the  gonococ- 
cus  as  is  the  membrane  higher  up ;  otherwise,  it  seems  to  him, 
a  greater  number  of  prostitutes  would  suffer  from  rectal  gon- 
orrhea. 

Symptoms. — In  gonorrheal  proctitis  there  is  a  profuse  dis- 
charge of  offensive,  yellow,  creamy  pus.  The  rectum  is  hot 
and  swollen,  and  the  pain  experienced  is  of  an  aching  or  burn- 
ing character.     In  addition,  these  patients  suffer  from  sphinc- 


Koch-Ehrlich  gentian-violet  {or  fttcJisin)  anilin-water-solution: — 

5  cubic  centimeters  of  pure  anilin-oil  are  vigorously  shaken  for  one 

or  two  minutes  with 
95  cubic   centimeters   of  distilled   water,    and   then   filtered   through   a 
moistened  filter-paper.     To  the  clear  filtrate,   upon  the  surface  of 
which  no  oil  drops  must  be  visible,  add 
11  cubic  centimeters  of  concentrated  alcohol  solution  of  gentian-violet 
or  fuchsin.     Mix  well  and  filter  through  moistened  filter-paper. 

This  solution  should  be  made  fresh  each  time  it  is  required.  If  it  Is  desirable  to 
preserve  the  solution  for  one  or  two  weeks,  10  cubic  centimeters  of  absolute  alcohol  can 
be  added  to  the  amount  mentioned  in  the  above  formula. 

Gram's  metliod:  Stain  one-half  to  one  minute  in  freshly  prepared  (or  but  a  few 
days  old)  Koch-Bhrlich  solution.  Remove  excess  of  stain  with  absorbent  paper  and 
place  for  one-half  to  one  minute  in  the  following  solution:— 

Oram's  solution: — 

Iodine  crystals  1  part. 

Potassium  iodide  , 2  parts. 

Distilled  water  300  parts.— M. 

Wash  in  absolute  alcohol  until  no  more  color  is  given  off;  dry  and  examine  la 
cedar-oil  with  V12  oil-immersion  lens.  The  gonococci  are  decolorized  by  this  method, 
while  the  pus-cocci  and  other  diplococci  retain  the  stain.  The  preparation  can  be 
counter-stained  with  a  fresh  saturated  watery  solution  of  Bismarck  brown,  then  washed 
In  water,  dried,  and  examined.  The  gonococci,  if  present,  take  up  the  brown  color,  aud 
are,  as  already  stated,  located  within   the  pus-cell-body  chiefly. 


VENEREAL  DISEASES  177 

terismus,  tenesmus,  painful  defecation,  pain  in  rectum  and  back 
when  exercising,  eversion  of  the  anal  mucosa,  sensations  of 
weight  and  fullness  in  the  rectum,  excoriations  of  the  buttocks, 
and,  when  the  inflammation  becomes  chronic,  ulceration,  pru- 
ritus, stricture,  and  hemorrhage. 

Diagnosis. — A  positive  diagnosis  of  gonorrheal  inflamma- 
tion can  be  made  in  one  way  only:  that  is,  by  the  detection 
of  the  gonococciis  by  the  aid  of  the  microscope.  Usually,  how- 
ever, a  previous  history  of  gonorrheal  infection  of  some  other 
organ  can  be  obtained.  In  simple  proctitis  the  inflammation  is 
less  active;  pain  is  not  so  severe;  the  discharge  is  odorless, 
thinner,  and  more  of  a  mucoid  character;  and  there  is  less 
excoriation  of  the  buttocks  than  when  it  is  due  to  gonorrhea. 

Prognosis. — As  far  as  the  author  is  aware,  a  death  from 
gonorrhea  of  the  rectum  has  never  been  recorded.  When  in- 
telligently treated,  this  disease  has  a  tendency  to  get  well  in 
a  few  weeks,  but  if  neglected  it  will  persist  for  many  months 
and  finally  result  in  stricture  or  ulceration,  abscess,  and  fistula. 

Treatment. — In  the  treatment  of  gonorrheal  proctitis  the 
best  results  are  obtained  by  absolute  rest  and  irrigation  of 
the  rectum  for  a  considerable  time  at  short  intervals  with 
sterile  water,  antiseptic  or  mild  astringent  solutions.  The  best 
instruments  for  this  purpose  are  the  Barger  irrigator  and 
Kemp  double-current  rectal  tube  (Figs.  43  and  56).  The 
liquids  used  should  be  as  hot  as  the  patient  can  bear,  for  the 
heat  soothes  the  mucous  membrane  and  diminishes  tenesmus 
and  sphincterismus.  Bichloride  of  mercury  (1  to  10,000)  and 
permanganate  of  potash  (1  to  3000),  saturated  solutions  of 
boric  acid,  and  silver  nitrate  (1  to  2500)  are  the  most  reliable 
agents.  Should  any  of  these  remedies  used  in  the  strengths 
mentioned  cause  colicky  pains,  weaker  dilutions  must  be  sub- 
stituted. Like  gonorrheal  urethritis,  gonorrhea  of  the  rectum 
can  sometimes  be  aborted.  Most  patients  do  better,  however, 
when  this  is  not  attempted,  because  such  treatment  is  occa- 
sionally followed  by  unpleasant  sequels.  Silver  nitrate,  10 
grains  to  the  ounce,  or  5-  to  15-per-cent.  solutions  of  pro- 
targol,  argentamin,  or  argonin  have  given  the  best  results  in 
abortive  treatment.  Spasm  of  the  sphincter  and  tenesmus  can 
be  alleviated  by  hot  fomentations  over  the  ano-perineal  region. 
When  pain  renders  rest  impossible,  suppositories  containing 
opium  and  belladonna  or  starch-water  and  laudanum  should 

12 


178  DISEASES  OF  THE  RECTUM  AND  ANUS 

be  introduced  into  the  rectum.  In  exceptional  cases  heat  fails, 
and  in  such  instances  cold  irrigation  and  the  ice-pack  over  the 
anus  and  lower  spine  afford  much  relief.  In  chronic  inflam- 
mation stronger  solutions  are  required,  and,  when  ulceration, 
stricture,  abscess,  and  fistula  are  present  as  complications,  they 
should  receive  radical  treatment.  During  the  course  of  gonor- 
rheal proctitis  it  is  well  to  remember  that  the  mucous  mem- 
branes of  other  parts  must  be  protected  from  infection. 


CHANCROIDS  (SOFT  CHANCRES) 

Etiology  and  Pathology.  —  Chancroids  are  encountered 
more  frequently  in  the  ano-rectal  region  than  are  either  chan- 
cres or  gonorrhea.  Infection  may  be  direct  in  sodomists  or 
indirect  in  prostitutes  suffering  from  soft  chancres  of  the 
genitals.  Unna  and  a  few  authorities  of  high  standing  believe 
this  disease  is  caused  by  bacilh.  Many  of  our  best  clinicians, 
however,  maintain  that  its  microbic  origin  has  not  as  yet  been 
satisfactorily  demonstrated.  That  chancroids  are  contagious 
and  auto-inoculable  is  admitted  by  all  authorities. 

Clinic  Manifestations. — The  period  of  incubation  is  short, 
— two  to  five  days, — practically  only  a  few  hours  when  the 
mucosa  is  lacerated  or  abraded.  As  a  rule,  the  sores  are 
multiple,  because  of  self-propagation,  sensitive  to  touch,  and 
vary  from  the  diameter  of  a  pea  to  that  of  a  penny.  They 
have  irregular  edges  and  an  inflamed  base,  which  is  pliable 
(soft),  and  secretes  a  copious,  purulent  discharge.  Their  tend- 
ency is  to  undermine  the  skin,  and  when  they  assume  a 
phagedenic  character  considerable  loss  of  tissue  results  (ser- 
piginous ulcer),  with  the  formation  of  extensive  scars.  This 
form  of  sore  requires  a  long  time  to  heal. 

Symptoms. — The  lymphatic  glands  of  the  inguinal  region 
become  enlarged  from  sympathetic  inflammation  or  direct 
infection.  When  due  to  the  former,  suppuration  seldom  fol- 
lows; when  due  to  the  latter,  it  is  exceptional  for  the  glands 
not  to  break  down.  Anal  chancroids  may  produce  a  fissured 
condition  of  the  anus,  painful  to  the  touch,  which  gives  rise 
to  intense  suffering  during  defecation.  The  discharge  from 
the  sores  keeps  the  buttocks  excoriated,  the  cutaneous  folds 
at  the  margin  of  the  anus  inflamed  and  swollen,  and  produces 
a  pruritus  which  is  extremely  difficult  to  relieve.    The  presence 


VENEREAL  DISEASES  179. 

of  chancroids  may  be  accompanied  by  extensive  ulceration, 
both  within  and  outside  the  rectum,  eventually  resulting  in  a 
tight  stricture  at  the  anal  margin  or  higher  up  the  bowel.  In 
fact,  Gosselin  and  Mason  have  written  exhaustively  upon  this 
subject,  and  takes  the  position  that  nearly  all  strictures  of  the 
rectum  and  anus  are  caused  by  these  sores.  This  is  an  atti- 
tude, however,  which  the  author's  experience  does  not  permit 
him  to  assume. 

Treatment. — Cleanliness  and  the  prevention  of  further  in- 
fection are  the  most  important  factors  in  the  treatment.  This 
can  be  accomplished  by  frequent  irrigation  with  any  one  of 
the  standard  antiseptic  solutions,  and  by  cauterization  of  the 
sores  with  the  actual  cautery  or  chemic  caustics,  such  as  nitric, 
sulphuric,  or  carbolic  acid,  or  lime  caustic.  Preferably  the 
Paquelin  cautery,  followed  by  mild  stimulation,  is  all  that  is 
required.  Ichthyol,  the  fluid  extract  of  krameria,  or  hydrastis, 
1-per-cent.  carbolic  acid,  and  weak  solutions  of  lead,  zinc,  and 
silver  are  reliable  remedies,  applied  either  directly  in  irriga- 
tions or  in  the  form  of  a  spray.  When  dry  powders  are  in- 
dicated, calomel,  iodoform,  citrate  of  silver,  orthoform,  aristol, 
bismuth,  and  salicylic  acid  render  faithful  service.  In  cases 
where  spJiiiicterisniiis  is  unbearable  and  cannot  be  relieved  by 
the  usual  measures,  the  muscles  should  be  thoroughly  divulsed 
or  divided,  as  circumstances  indicate.  Ulcers  that  become 
chronic  require  curettage,  and  when  extensive,  bougies  should 
be  occasionally  inserted  to  prevent  too  much  contraction  dur- 
ing healing.  Tight  strictures  from  chancroids  are  treated  in 
the  same  manner  as  constrictions  in  the  rectum  from  other 
causes,  as  outlined  in  a  separate  chapter. 


SYPHILIS 

Hereditary  or  acquired  syphilis  is  occasionally  encount- 
ered in  the  ano-rectal  region.  It  may  manifest  itself  in  the 
form  of  chancres,  mucous  patches  (mucous  plaques),  condy- 
lomata, gummatous  deposits,^  ulceration,  and  strictures. 

Chancres  (Initial  Lesions).  —  Chancres  are  common  to  all 
ages,  ranks,  and  vocations,  and  are  encountered  in  all  parts 
of  the  body.  They  are  met  with  about  the  rectum  and  anus 
more  frequently  than  is  generally  supposed  by  physicians  who 
do  little  rectal  work.    For  obvious  reasons,  women  suffer  from 


180  DISEASES  OF  THE  RECTUM  AND  ANUS 

them  oftener  than  men.  The  anus  is  affected  once  in  about 
every  fifty  cases  in  women  and  once  in  every  four  hundred 
in  men.  Male  subjects  suffering  from  an  anal  or  rectal  initial 
lesion  will  frequently  prove  to  be  pederasts.  Chancres  of  the 
anus  have  about  the  same  stage  of  incubation  as  similar  sores 
in  other  parts,  namely :  from  twenty-one  to  twenty-eight  days. 
They  are  single,  distinct,  firm,  cup-shaped  sores,  with  rounded 
edges,  manifesting  no  tendency  to  undermine  the  skin.  The 
non-inflammatory  base  tends  rather  to  heal  than  to  spread,  and 
gives  off  a  slight  discharge  which  is  never  auto-inoculable. 
They  cause  induration,  but  not  breaking  down,  of  the  inguinal 
glands.  Except  when  congenital,  they  are  located  at  the  exact 
point  of  entrance  of  the  virus.  Lustgarten  claimed  to  have  dis- 
covered the  bacillus  of  syphilis,  but  many  prominent  syphi- 
lographers,  himself  among  the  number,  do  not  now  accept  this 
micro-organism. 

Mixed  Sores  are  occasionally  met  with  in  this  region  in 
persons  suffering  from  chancroids,  syphilis  having  been  ac- 
quired at  a  subsequent  date ;  such  sores  possess  some  of  the 
characteristics  of  both  chancre  and  chancroid. 

Symptoms. — A  chancre  may  be  easily  mistaken  for  a  fissure 
or  simple  ulceration  unless  suspicion  as  to  its  presence  is 
aroused.  They  cause  slight  discomfort  during  defecation, 
moderate  sphincterismus,  and  a  thin  discharge  which  excites 
pruritus.  When  kept  clean  they  heal,  but  when  let  alone  they 
sometimes  develop  a  mucous  patch. 

Treatment. — The  excision  method  which  was  in  vogue  for 
a  time  is  seldom  resorted  to  at  the  present  day,  for  the  reason 
that  the  disease  is  considered  constitutional  from  the  moment 
the  virus  enters  the  body.  Chancres  require  mild  treatment: 
cleanliness  and  a  simple  dusting-powder,  such  as  calomel,  bis- 
muth, or  iodoform.  They  never  should  be  cauterized  except 
when  they  become  phagedenic,  and  constitutional  remedies 
are  not  indicated  until  the  eruptive  stage. 

Secondary  Syphilis.  —  Persons  suffering  from  syphilitic  in- 
fection in  the  ano-rectal  region  develop  the  same  manifesta- 
tions of  the  skin  and  mucous  membrane  as  occur  when  the 
disease  is  contracted  in  the  usual  way.  The  following  table, 
arranged  by  Sturgis.  gives  the  eruption  stages,  when  they  may 
be  expected,  and  their  duration : — 


PLATE  XL— INFECTIOUS  [Sypbilitic]  CONDYLOMATA  {Condylomata 
Lata]  Involving  the  Anus,  Peals,  and  Interdlgital  Spaces- 


VENEREAL  DISEASES  181 

Name  Due  Dcration 

Erythema 6-12  ^Yeeks.  3-6  weeks. 

Papules    2-  6  months.  4-8  weeks. 

Pustules     0-15  months.  2-4  months. 

Gummata    1-  5  years  and  more.  A-2  years  and  more. 

The  secondary  manifestations  of  syphilis  about  the  rectum 
and  anus  are  superficial,  and  more  amenable  to  treatment  than 
those  of  the  tertiary  stage. 

Mucous  Patches  (moist  or  syphilitic  papules;  mucous 
plaques)  of  the  rectum  and  skin  of  the  ano-perineal  region 
cause  considerable  annoyance,  and  become  extensive  when  per- 
mitted an  uninterrupted  course.  They  may  appear  upon  the 
membrane  or  integument  as  superficial  erosions  and  be  mis- 
taken for  fissure  or  simple  ulceration,  or  when  not  kept  dry 
they  may  undergo  hypertrophic  changes,  resulting  in  the 
formation  of  cauliflower  excrescences  (condylomata  lata),  de- 
scribed elsewhere. 

Congenital  Syphilis. — Mucous  patches  are  of  frequent  oc- 
currence in  children  suffering  from  hereditary  syphilis.  The 
lower  inch  of  the  rectum  and  the  skin  around  the  anus  may 
be  completely  covered  with  them.  They  extend  in  every  direc- 
tion, and  ulcerate,  forming  long,  deep  fissures  (Plate  I), 
which  radiate  toward  the  anus.  In  these  children  the  angles 
of  the  mouth  and  the  vulva  are  similarly  affected.  The  sores 
secrete  an  offensive  mucoid  discharge,  which  is  highly  con- 
tagious. 

Gummatous  infiltration  of  the  intestine  is  rare  in  young 
children  and  usually  fatal. 

Symptoms.  —  The  principal  manifestations  of  mucous 
patches  about  the  ano-perineal  region  and  rectum  are  ero- 
sion of  the  parts,  pain  on  walking  and  after  defecation,  intense 
pruritus,  slight  hemorrhage;  dirty,  foul-smelling  secretion; 
proctitis,  ulceration  and  fissures  in  and  outside  the  bowel  fre- 
quently condylomatous  masses,  and  sometimes  abscess  and 
fistulas. 

Treatment.  —  Constitutional  (mercurial)  and  local  treatment 
are  both  indicated,  the  former  to  prevent  farther  extension 
of  the  disease,  and  the  latter  to  heal  ulceration  already  pres- 
ent. Mucous  patches  and  the  ulcers  caused  by  them  are  best 
treated  by  cleanliness,  keeping  the  parts  dry  and  the  buttocks 
separated  by  gauze  to  prevent  farther  infection,  and  the  topic 


182  DISEASES  OF  THE  RECTUM  AND  ANUS  ; 

application  of  antiseptic  and  astringent  powders  and  lotions  as 
outlined  in  the  treatment  of  condylomata.  When  such  time- 
honored  remedies  as  calomel,  iodoform,  orthoform,  tannic  acid, 
and  the  citrate  of  silver  fail,  chemic  caustics  and  the  potential 
cautery  should  be  used.  When  condylomata  are  present  as  a 
complication,  they  should  be  curetted  or  cut  off,  and  their  bases 
well  seared  with  the  Paquelin  cautery. 

CONDYLOMATA  (VENEREAL  WARTS,  VEGETATIONS,  MUCOUS 
PATCHES,   PAPILLOMATA,   DERMOPHYMATA  VENEREA) 

Condylomata  (Konduloma:  a  knot,  eminence)  are  soft, 
fleshy  excrescences,  of  white  or  pinkish  hue,  occurring  singly, 
multiple,  or  en  masse.  They  vary  in  size  from  the  point  of  a 
pin  to  patches  two  inches  (5.08  centimeters)  in  width.  The 
form  may  be  pointed,  club  shaped,  fiat,  or  villous.  They  occur 
at  all  ages,  but  are  most  often  observed  in  young  adults. 
Females  are  more  often  affected  than  males. 

Condylomata  are  quite  common  upon  the  nates  and  in 
the  ano-rectal  region,  especially  in  prostitutes  and  sodomists 
of  unclean  habits.  They  develop  alike  upon  the  skin  and  mu- 
cous membrane,  and  may  completely  encircle  the  anus.  They 
are  of  two  kinds:    condyloma  latum  and  condyloma  acuminatum. 

Condyloma  Latum  (Syphilitic  Condyloma),  the  fiat  form  (Plate 
XI),  occurs  only  in  syphilitic  subjects,  and  may  be  either  he- 
reditary or  acquired.  The  condition  may  first  manifest  itself 
as  slightly-inflamed  red  spots  with  raised  epidermis.  The 
latter  is  soon  cast  off  as  a  result  of  irritation,  leaving  the  raw 
surface  bathed  in  a  mucoid  discharge.  When  kept  dry  and 
clean,  these  sores  rapidly  heal.  If,  however,  the  secretions  are 
permitted  to  accumulate  and  decompose,  hypertrophic  changes 
take  place.  As  these  exuberances  increase  in  extent  the  typic, 
flat,  irregularly-nodulated  masses  are  formed.  They  consti- 
tute the  true  syphilitic  condylomata.  The  latter  are  whitish 
in  tint,  single  or  multiple  in  number,  and  exude  a  foul-smell- 
ing, auto-inoculable  secretion.  They  vary  from  pea  to  hand 
size,  and  manifest  a  decided  tendency  to  coalesce.  New 
growths  in  every  way  similar  to  the  original  condylomata 
spring  up  in  those  parts  of  the  sound  skin  in  contact  with 
them.  This  variety  of  condyloma  is  frequently  one  of  the 
earliest  manifestations  of  congenital  syphilis,  and  is  more 
common  about  the  anus  than  in  other  parts.     The  author  has 


PLATE  XII.— NON-SYPHILITIC  CONDYLOMATA 

[Condylomata  Acuminata}. 


VENEREAL  DISEASES  183 

seen  syphilitic  condylomata  about  the  anus  of  children  suffer- 
ing from  congenital  syphilis. 

Condyloma  Acuminatum  (Venereal  Wart;  Vegetation;  Papil- 
loma).—  Non-syphilitic  discharges — gonorrheal,  leucorrheal, 
chancroidal,  etc. — which  keep  the  buttocks  and  recto-anal 
region  constantly  moistened,  frequently  result  in  the  produc- 
tion of  vegations  in  these  parts  (Plates  XII  and  XIII).  Such 
wart-like  excrescences  are  called  condylomata  acuminata.  The 
prolonged  irritation  kept  up  by  the  secretions  in  time  causes 
hypertrophy  of  the  neighboring  papillae. 

"The  papillae  as  they  grow  tend  more  and  more  to  sub- 
divide; they  are  composed  essentially  of  vascular  fibrous  tis- 
sue, but  always  inclose  a  number  of  leucocytes,  and  the  base 
on  which  they  stand  is  always  infiltrated.  A  proliferous  lym- 
phangitis is  often  set  up  at  the  same  time,  as  appears  by  the 
accumulation  of  cells  within  and  around  the  efferent  lymph- 
vessels  of  the  affected  part.  The  epidermis  over  the  hyper- 
trophic papillae  is  thickened,  and  somewhat,  though  not  en- 
tirely, effaces  the  unevenness  (cauliflower  appearance)  caused 
by  the  branching  of  the  papillae. 

"Inflammatory  fibrous  papilloma  and  papillomatous  gran- 
uloma fungoides  are  closely  akin,  and  accordingly  it  is  not  easy 
to  differentiate  them."     (Ziegler.) 

Condylomata  acuminata  are  encountered  most  often  in 
middle  life,  though  they  are  sometimes  met  with  in  old  people 
and  young  children.  Stout  people  whose  buttocks  remain  in 
contact  are  particularly  prone  to  them.  They  occur  more  fre- 
quently in  women  than  in  men.  They  are  not  so  fragile,  but 
are  segmented  and  less  contagious  than  warts  induced  by  syph- 
ilitic secretions. 

Symptoms. — Condylomata  in  this  region  resemble  warts  of 
other  parts  of  the  body,  except  that  they  are  more  fragile, 
easily  broken  off,  and  bleed  freely  from  the  slightest  irritation. 
They  may  appear  singly,  but  usually  occur  in  patches,  attached 
by  small  pedicles,  while  their  outer  extremities  bifurcate, 
producing  a  cauliflower  effect  when  they  are  present  in  great 
numbers.  The  secretion  is  abundant,  very  offensive,  and  be- 
comes unbearable  as  the  disease  extends ;  it  keeps  the  but- 
tocks constantly  excoriated  and  painful,  and  induces  a  pruritus 
difiticult  to  relieve.  Sooner  or  later  fissures  and  deep  ulcers 
with  raised  edges  are  formed  in  the  skin  around  the  anus  and 


184  DISEASES  OF  THE  RECTUM  AND  ANUS 

in  the  mucous  membrane  of  the  lower  inch  of  the  rectum.  As 
a  result  of  this,  these  patients  suffer  from  tenesmus,  sphinc- 
terismus, proctitis,  local  and  reflected  pain  which  is  aggravated 
by  defecation,  and  slight  hemorrhages,  and  they  may  event- 
ually have  a  stricture.  When  condylomata  are  few  in  number, 
little  inconvenience  is  caused  either  by  walking  or  sitting;  on 
the  contrary,  when  they  are  present  in  large  patches,  sur- 
rounding the  anus  and  filling  in  the  intergluteal  space,  exercise 
becomes  impossible.  When  allowed  an  uninterrupted  course 
they  may  undergo  malignant  degeneration. 

Diagnosis. — It  is  important,  but  not  always  easy,  to  differ- 
entiate between  condylomata  induced  by  non-syphilitic  secre- 
tions and  those  secondary  to  a  syphilitic  discharge.  Every- 
thing depends  on  securing  a  clear  history  as  to  whether  the 
patients  have  ever  suffered  from  venereal  or  other  affections 
known  to  produce  condylomata.  "The  microscope  will  show 
hypertrophy  of  the  rete  MalpigJiii  when  non-syphilitic,  and  a 
hypertrophy  of  the  branching  papillae  when  they  are  of  syph- 
ilitic origin"  (Kelsey).  It  is  hardly  necessary  to  add  that  this 
close  distinction  is  not  always  observable.  The  author  has  seen 
one  case,  that  of  a  young  woman,  where  the  warts  appeared  to 
be  mixed.  The  patient  had  both  syphilis  and  gonorrhea  at  the 
same  time.  One  set  of  growths  seemed  to  spring  directly  out 
of  the  skin  and  the  other  from  mucous  patches. 

Treatment. — Condylomata  of  syphilitic  origin  require  anti- 
syphilitic,  constitutional,  and  local  treatment,  while  those  in- 
duced by  non-syphilitic  discharges  need  local  treatment  only. 
These  vegetations  should  be  radically  treated,  because  their 
tendency  is  to  return,  and,  if  one  is  left,  others  quickly  follow. 
When  surgical  interference  is  declined,  much  can  be  accom- 
plished by  palliative  measures,  but  a  longer  time  is  required 
to  effect  a  cure.  They  should  be  cleansed  frequently  with  some 
antiseptic  solution,  and  the  buttocks  kept  separated  by  gauze 
or  cotton,  to  take  up  the  secretions  and  to  prevent  irritation 
and  spread  of  the  disease.  In  most  instances  they  can  be  made 
to  dry  up  by  keeping  them  dusted  with  powdered  zinc,  alum, 
iron,  tannin,  silver,  or  calomel ;  the  latter  is  of  especial  value 
in  the  syphilitic  type ;  the  black  and  yellow  washes  also  render 
good  service.  If  under  this  treatment  improvement  is  slow, 
cauterization  with  sulphuric,  nitric,  or  carbolic  acid  should  be 
tried,  care  being  taken  to  protect  the  healthy  tissue.     They 


EXPLANATION  OF  PLATE  XIII 


The  growth  starts  just  at  the  point  where  the  epider- 
mis folds  inward  to  become  the  internal  stratified 
mucous  membrane. 

Beginning  at  the  lower  right-hand  corner,  the  dark 
line,  y\  inch  thick,  is  the  internal  mucous  membrane, 
which  gradually  thickens  and  then  suddenly  becomes 
transformed  into  the  excessive  branching  excrescence  of 
the  tumor. 

The  growth  itself  consists  primarily  of  stratified  epi- 
thelium in  which  the  horny  layer  is  inconspicuous,  while 
the  rete  Malpighii  is  greatly  thickened  and  prominent. 
The  papillae  of  the  cutis  vera  are  greatly  elongated  and 
narrowed,  showing  the  excessive  branching  which  is  so 
characteristic  of  condylomata  acuminata. 

Above,  the  growth  shades  o£E  into  the  external 
epidermis. 

There  is  secondarily  a  considerable  increase  in  the 
connective  tissue  underlying  the  epidermis,  appearing 
light  in  the  print.  Numerous  blood-vessels  can  be  seen 
in  the  connective  tissue,  and  the  darker  areas  in  the 
upper  portion  just  underlying  the  line  of  normal  epider- 
mis represent  hair-follicles  and  dilated  sweat-glands. 


FLUTE  XIII 


_  .*»,l^f^  ^^5«\ 


%. 


Q' 


V" 


^— ■ 


.# 


Candylnma  [Ecuminatnm]  Rni,     [Magnifinatinn,  5,] 


VENEREAL  DISEASES  185 

should  then  be  dried  and  powdered  with  one  of  the  remedies 
above  named.  In  case  they  are  not  ah  destroyed  by  this  pro- 
cedure, nothing  short  of  surgical  measures  will  eradicate  them. 
The  safest,  quickest,  and  best  results  in  the  treatment  of  con- 
dylomata are  to  be  had  by  clipping  them  off  with  scissors  and 
cauterizing  their  bases  with  the  Paquelin  cautery;  when  thor- 
oughly done,  this  treatment  never  fails. 

Gummata  of  the  Rectum  and  Anus  ( Ano-rectal  Syphiloma) 

Gummatous  deposits  are  met  with  more  frequently  in  the  rec- 
tum than  in  any  other  part  of  the  intestine.  Women  suffer 
from  them  more  often  than  men.  They  may  be  single  or 
multiple,  circumscribed  or  diffused,  are  variable  in  shape,  may 
occur  in  any  part  of  the  rectum  and  attack  the  mucous  mem- 
brane, submucosa,  muscular  coats,  or  perirectal  tissues. 

The  deposits  begin  usually  in  the  submucosa,  and  grad- 
ually extend  until  they  give  a  lobulated  appearance  to  the 
inner  bowel.  As  a  result  of  obstructed  circulation  and  the 
irritation  caused  by  the  feces,  these  projections  in  time  disin- 
tegrate, leaving  deep,  crater-like  ulcers,  which  secrete  an 
abundance  of  pus.  Exuberant  granulations  may  start  from 
these  ulcers,  forming  fungus-like  masses,  which  may  be  mis- 
taken for  malignant  disease. 

The  tendency  of  the  ulcers,  however,  is  to  extend  until 
the  mucosa  of  the  lower  rectum  is  almost,  if  not  completely, 
destroyed.  As  healing  takes  place,  a  tight  unyielding  stricture 
is  produced  because  of  the  induration  and  formation  of  fibrous 
tissue.  In  exceptional  cases,  the  gummatous  deposits  are 
located  in  the  perirectal  tissues  and  break  down  and  ulcerate 
into  the  rectum  or  adjacent  organs;  or  they  may  ulcerate 
through  the  skin,  causing  abscess  and  fistula. 

An  unusual  manifestation  of  the  later  stages  of  syphilis  is 
stricture,  involving  the  entire  circumference  of  the  bowel,  due, 
not  to  a  preceding  ulceration,  but  to  gummatous  infiltration, 
from  which,  as  a  result  of  chronic  inflammatory  processes,  the 
musculature  appears  to  undergo  fibrous  degeneration  and  con- 
traction. When  it  is  limited  to  a  narrow  ring,  it  is  designated 
as  annular  stricture,  and,  when  several  inches  of  the  rectum  are 
affected,  tubular  stricture. 

This  condition  Fournier  has  described  under  the  caption 
"ano-rectal  syphiloma,'"  and  he  maintains  that  this  is  the  only 
way  stricture  can  be  caused  by  syphilis. 


186  DISEASES  OF  THE  RECTUM  AND  ANUS 

Many  cases  of  gummata  of  the  rectum  have  been  reported. 
The  most  celebrated  are  those  recorded  by  Verneuil,  Schiff, 
Brown,  Coote,  Ross,  MacMaster,  Taylor,  Zappula,  Molliere, 
Leisol,  Barduzzi,  and  Lecorche.  While  in  some  of  these  cases 
the  diagnosis  cannot  be  doubted,  a  close  analysis  forces  the 
belief  that  the  majority  of  the  patients  suffered  from  neoplasms 
of  other  than  syphilitic  origin. 

Many  patients  afflicted  with  constitutional  syphilis  have 
been  treated  by  the  author  for  rectal  stricture.  The  author  has 
seen  only  one  case,  however,  in  which  ulceration  or  contraction 
had  not  already  occurred,  and  in  which  he  was  positive  that 
the  occlusion  was  due  to  gummatous  deposits  (Case  IV,  page 
187). 

Symptoms  and  Diagnosis. — Gummata  of  the  rectum  may  be 
overlooked  or  incorrectly  diagnosticated  because  of  their 
rarity. 

The  manifestations  of  gummata  in  the  rectum  depend 
upon  the  size,  number,  and  condition  of  the  deposits.  When 
slight  and  not  ulcerated,  they  cause  constipation.  When  more 
extensive  and  ulcerated,  frequent  fluid  stools  with  prolonged 
straining;  discharge  of  pus,  blood,  and  mucus;  local  and 
reflected  pains ;  emaciation,  and  sometimes  destruction  of  the 
sphincter-muscle  occur.  When  allowed  an  uninterrupted 
course,  the  usual  symptoms  common  to  obstruction — stricture 
and  ulceration — manifest  themselves  at  some  stage  of  the 
disease. 

Treatment.  —  Antisyphilitic  treatment  is  indicated  in  the 
later  stages  of  syphilis,  for  two  reasons :  first,  to  aleviate  the 
existing  condition  of  its  victims,  and,  second,  to  prevent  an 
extension  of  the  disease. 

The  bichloride  of  mercury  in  doses  of  Vso  (0.0013  gram) 
to  Vio  (0.0065  gram)  grain  or  the  protiodide  Vs  (0.013  gram) 
to  V2  (0.033  gram)  grain  are  reliable  remedies.  Sturgis  pre- 
fers a  blue-mass-and-iron  pill,  and  recommends  about  6  grains 
(0.39  gram)  of  the  blue  mass  daily,  to  be  continued  until  the 
toxic  effect  is  produced  or  the  lesions  have  disappeared. 

When  gummatous  infiltration  has  taken  place,  potassium 
iodide  administered  in  large  quantities  of  any  reputable  min- 
eral water  is  the  remedy  pai'  excellence.  Starting  with  30  grains 
(2  grams),  the  dose  should  be  increased  10  grains  (0.65  gram) 
each  day  until  from  250  to  500  grains  (16.25  to  32.5  grams) 


VENEREAL  DISEASES  187 

daily  are  reached.  When  the  toxic  effect  of  the  drug  mani- 
fests itself  in  coryza  and  the  typic  pustules  on  the  shoulders, 
the  treatment  should  be  suspended  for  a  few  days. 

Massage  and  electricity  in  conjunction  with  the  above 
treatment,  while  not  always  reliable,  occasionally  do  much 
good.  A  gummatous  deposit  may  be  extirpated,  but  should 
never  be  incised. 

When  the  suffering  of  these  patients  becomes  unbearable, 
as  a  result  of  constriction  and  ulceration,  a  colostomy  should 
be  made,  because  most  local  operations  fail  to  give  permanent 
relief. 

VENEREAL  DISEASES  OF  THE  RECTUM  AND  ANUS  CAUSED 
BY  SODOMY  AND  RECTAL  ONANISM 

The  rectum  and  anus  are  frequently  the  seat  of  disease 
and  injury  in  persons  guilty  of  sodomy  where  the  male  organ 
is  received  per  rectum  (pederasty)  by  either  sex. 

Excluding  the  venereal  diseases  already  described,  the  fol- 
lowing ailments  and  injuries  are  the  most  common  in  those 
who  gratify  their  sexual  appetite  in  this  disgusting  manner: 
Proctitis,  ulceration,  abrasions,  ecchymoses,  fissures,  hemor- 
rhage, incontinence,  hypertrophy  or  rupture  of  the  sphincter, 
stricture,  abscess,  and  fistula. 

Rectal  Onanism  (Masturbation)  is  occasionally  resorted  to  by 
elderly  men  who  are  incapable  of  having  natural  intercourse. 
The  rectum  and  anus  are  sometimes  injured  by  candles,  bottles, 
pieces  of  wood,  and  other  objects  introduced  to  excite  sexual 
orgasm. 

The  various  diseases  and  injuries  resulting  from  pederasty 
and  rectal  masturbation  are  more  fully  described  in  a  separate 
chapter. 

ILLUSTRATIVE   CASE 

Case  IV.  Gummata  of  the  Rectum. — A  prostitute,  30  years  of  age,  had 
contracted  syphilis  six  years  previous,  the  progress  of  the  disease  being  marked 
by  the  usual  eruptive  manifestations:  mucous  patches  and  sore  throat.  In 
spite  of  these  warnings,  she  refused,  because  of  their  bad  taste,  to  take  the 
constitutional  remedies  prescribed. 

She  was  referred  to  me  to  be  treated  for  chronic  diarrhea  attributed  to 
colitis,  and  which  had  persisted  for  more  than  a  year.  She  complained  of 
frequent  stools,  prolonged  straining,  bearing-down  pains,  weight  and  fullness, 
and  a  sensation  of  the  presence  of  foreign  bodies  in  the  rectum,  copious  dis- 


188  DISEASES  OF  THE  RECTUM  AND  ANUS 

charges  of  mucus;  and  on  evacuation  the  feces  were  never  natural  in  form  or 
consistence.  Examination  revealed  four  ovoid  masses,  two  or  three  inches 
(5.08  or  7.62  centimeters)  above  the  anus,  plainly  visible  through  the  procto- 
scope, and  causing  almost  complete  occlusion.  They  appeared  to  be  about 
half  an  inch  (1.27  centimeters)  thick,  and  varied  in  length  from  one  to  two 
inches  (2.54  to  5.08  centimeters).  Two  were  located  on  the  anterior  wall,  one 
in  the  posterior,  and  the  fourth  on  the  left  side  of  the  rectum.  They  were 
smooth,  firm,  slightly  elastic,  and  evidently  had  their  origin  in  the  submucosa. 

I  made  a  diagnosis  of  carcinoma,  and  advised  a  Kraske,  which  was 
promptly  refused.  I  then  suggested  left  inguinal  colotomy,  and  this  was  also 
declined,  with  the  remark  that  she  would  not  submit  to  an  operation,  but 
would  undergo  any  other  treatment.  Potassium  iodide,  in  large  quantities  of 
mineral  water,  was  prescribed,  20  grains  (1.3  grams)  three  times  a  day  and 
gradually  increased  until  300  grains  (19.5  grams)  daily  was  reached.  This  was 
discontinued  for  a  few  days  on  account  of  iodism,  and  then  resumed  for  six 
weeks  longer.  From  the  beginning  of  the  treatment  the  lumen  of  the  bowel 
was  kept  open  and  the  tumors  massaged  three  times  weekly  by  the  insertion 
of  Wales  graduated  bougies. 

After  two  weeks'  treatment  the  tumors  were  noticeably  smaller,  and  at 
the  end  of  ten  weeks  they  had  completely  disappeared;  the  rectum  was  free 
and  smooth,  and  the  annoying  symptoms  were  relieved.  I  examined  the 
patient's  rectum  several  times  during  the  following  six  years,  and  at  no  time 
was  there  any  evidence  of  a  return  of  the  disease. 


LITERATURE  ON  VENEREAL  DISEASES  OF  THE 
RECTUM  AND  ANUS 


Bacon:    "Syphilitic  Stricture,"  Amer.  Jour.  Surg,  and  Gi/nec,  vol.  xi,  p.  112, 

1898-99. 
Baer:    "Weitere  Beitrage  zur  Lehre  von  der  weiblichen  Rectalgonorrhoe,"  Deut, 

med.  Wchnschr.,  vol.  xxxiii,  pp.  811-33.    Leipzig  u.  Berlin,  1897. 
Benton:    "Colotomy  for  Syphilitic  Stricture,"  Illiist.  Med.  News,  London,  vol.  i, 

p.  55,  1888-89. 
Brown:    "Syphilitic  Stricture,"  Maryland  Med.  Jour.,  vol.  xiii,  p.  468,  1885. 
Coote:   "Syphilitic  Stricture,"  Med.  Times  and  Gaz.,  vol.  x,  p.  82.    London,  1855. 
Depres:    "Des  Chancres  Phagedeniques,"  etc..  Arch.  Gen.  de  Med.    Paris,  1882. 
Dowse:    "Syphilitic  Diseases,"  Path.  Society,  London,  vol.  xxvi,  p.  Ill,  1874-75. 
Fournier:     "Lesions  tertiares  de  I'anus,"  etc.,   French  Med.,  vol.  xxi,  p.   641. 

Paris,  1874. 
Fuller:    "Diseases  of  the  Genito-Urinary  System,"  1900. 
Godebert:     "Sur  les  retrecissements  syphilitiques,"   etc.     Paris,   1893. 
Gosselin:    "Des  retrecissements  syphilitiques,"  etc..  Arch.  G6n.  de  MM.,  vol.  iv, 

p.  667,  1854. 
Goulson:    "Syphilis."    London,  1869. 
Hahn:    "Zur  Behandlung  der  syphil.  Mastdarmulcer,"  etc.,  Archiv  f.  klin.  Vhir., 

p.  395.     Berlin,  1883. 


VENEREAL  DISEASES  189 

Howse:    "Syphilitic  Ulceration,"  Chiy's  Hosp.  Gaz.,  pp.  1-4.    London,  1872. 

Hyde-Montgomery:    "Syphilis  and  Venereal  Diseases,"  1896. 

Jullien :  "Note  sur  le  blennorrhagie  ano-rectal,"  etc.,  Assoc.  franQ.  de  chir.  Proc- 

verb.,  Paris,  vol.  x,  pp.  465-69,  1896. 
Kelsey:    "Venereal  Diseases,"  Med.  Record,  N.  Y.,  vol.  xxx,  p.  623,  1886. 
Keyes  and  Chetwood:    "Venereal  Diseases,"  1900. 

Maclaren:    "Venereal  Diseases,"  Edln.  Clin,  and  Path.  Jour.,  vol.  i,  p.  593,  1834. 
Marot:    "Syphilome  ano-rectal,"  Bull.  Soc.  d'Anat.  de  Paris,  vol.  lii,  p.  356, 

1877. 
Marshall:    "Treatment  of  Stricture,"  Lancet,  London,  vol.  i,  p.  8,  1870. 
Mason:    "Venereal  Stricture,"  Amer.  Jour.  Med.  Sciences,  vol.  x,  p.  22,  1893. 
Monnot:    "Contribution  a  I'etude  du  syphilome  ano-rectal."     Paris,  1882. 
Probst:     "Ueber   Syphilitische  Mastdarmgeschwtire."     Berlin,   1868. 
■Quenu  and  Hartmann:    "Syphilis,"  "Chirurgie  du  Rectum."     Paris,  1895. 
Romiti:     "Alteraziono  anatomische  del  Retto  in  una  sifilitica,"  Bull.  d.  Soc. 

trat.  cult.  sc.  Med.  in  Sienna,  vol.  i,  p.  55,  1883. 
Rona:    "Gine  durch  Gonorrhea  recti,"  etc..  Pest.  Med.-CMr.  Presse,  vol.  xxxiii, 

p.  546.    Budapest,  1897. 
Sturgis:    "Cases  of  Syphilis,"  Amer.  Jour.  Med.  Sci.,  vol.  Ixv,  p.  102,  1873. 
Sturgis  and  Cabot:    "Syphilis,"  seventh  edition,  1901. 
Taylor:     "Diseases  of  the  Genito-Urinary  System,"   1900. 

"Syphilitic  Lesions,"  Jour.  Cutan.  and  Yen.  Dis.,  vol.  iv,  p.  225,  1886. 
Verneuil:    "Gumma  of  the  Anus,"  Gaz.  des  Hopitaux,  p.  202,  1888. 
White  and  Martin:    "Syphilis,"  fourth  edition,  1901. 
Zappula:    "Un  Raro  caso  di  stringimenta,"  etc.,  Ann.  Univ.  di  Med.,  Milano, 

vol.  ccxiii,  p.  157,  1870. 
Ziegler:    "Syphilis  of  the  Rectum,"  Text-book  Spec.  Patk.  Anat.,  p.  674,  1898. 


CHAPTER  XII 

ETIOLOGY,  PATHOLOGY,  SYMPTOMS,    AND   DIAGNOSIS  OF 

PRURITUS  ANI  (ITCHING  OF  THE  ANUS, 

ITCHING  PILES) 

Pruritus  ani  is  an  affection  which,  in  its  typic  form,  is 
characterized  by  persistent  and  intense  itching  of  the  ano- 
gluteal  region,  excoriation  of  the  parts,  and  transformation  of 
the  skin  about  the  anus  into  radiating,  indurated,  thick,  parch- 
ment-Hke  folds.  Pruritus  is  common  to  adult  hfe,  more  fre- 
quently affects  men  than  women,  and  is  rarely  seen  in  children. 
It  attacks  persons  in  all  walks  of  life,  all  climates,  all  vocations, 
and  the  thin  as  well  as  the  stout.  Persons  of  sedentary  occu- 
pations are  frequent  sufferers.  Individuals  of  neurotic  tend- 
ency, those  who  are  fat  or  perspire  freely,  and  those  who  have 
a  tender  skin  are  especially  disposed  to  pruritus. 

ETIOLOGY  AND   PATHOLOGY 

Since  this  affection  under  discussion  is  rather  a  symptom 
than  a  disease,  it  is  readily  understood  why  the  etiology  of 
pruritus  ani  is  more  obscure  and  has  been  the  subject  of  greater 
discussion  than  that  of  any  other  disease  occurring  in  the  anal 
reeion.  The  reason  for  this  is  that  the  cause  of  the  affection 
in  one  case  may  be  so  widely  different  from  that  in  another. 
There  seems  to  be  little  doubt  that  anal  pruritus  is  largely  in- 
fluenced by  an  inherited  or  acquired  neurotic  condition,  and 
that  it  may  or  may  not  be  of  parasitic  origin.  Again,  it  can 
be  demonstrated  conclusively  that  pruritus  is  frequently  di- 
rectly or  indirectly  due  to  (a)  local  disease  of  the  colon,  rec- 
tum, or  anus,  (h)  improper  diet,  (c)  cutaneous  affections  in  the 
ano-gluteal  region,  (d)  operations  about  the  rectum  and  anus, 
(e)  disease  in  neighboring  organs,  and  (f)  systemic  diseases. 

Local  Disease  of  the  Colon,  Rectum,  or  Anus  is  undoubtedly  a 
very  common  cause  of  pruritus.  The  author  has  treated  many 
cases  of  pruritus  ani  which  did  not  exist  prior  to  the  onset  of 
some  local  disease  in  the  colon,  rectum,  or  anus.  Any  condi- 
tion accompanied  by  diarrhea  or  discharges  of  mucus  and  pus, 
(190) 


PEURITUS  ANI  191 

which  excoriate  the  parts,  may  set  up  a  persistent  pruritus. 
The  most  common  of  these  conditions  are  fissure;  polyps; 
prolapse;  ulceration^  mahgnant,  specific,  or  otherwise;  fist- 
ula; condylomata;  hemorrhoids,  when  ulcerated;  gonor- 
rhea; foreign  bodies;  acute  and  atrophic  proctitis;  fecal 
impaction ;  stricture ;  colitis ;  enteroliths ;  oxyuris  vermicu- 
laris;  cestodes.  Again,  pruritus  ani  may  be  caused  by  any 
affection  of  the  ano-rectal  region  which  induces  a  neuritis, 
causes  pressure  upon  a  nerve,  or  exposes  the  terminal  filaments 
to  irritation,  viz. :  neoplasms,  chronic  inflammations  or  ulcera- 
tions of  whatever  kind,  presence  of  foreign  bodies,  fecal  im- 
paction, and  the  retention  and  decomposition  of  the  intestinal 
or  other  secretions  or  excretions  which  find  their  way  into  the 
rectum.  Moreover,  any  of  the  last-named  processes  may  in- 
duce this  condition  by  obstructing  the  circulation  at  the  anal 
outlet  and  causing  venous  stagnation. 

Diet,  Irregular  Habits,  and  Dissipation  are  important  factors 
in  producing  and  aggravating  itching  at  the  anus.  Over- 
seasoned  foods,  lobster,  salmon,  shell-fish,  and  foods  contain- 
ing large  quantities  of  grease  or  starch  are  especially  con- 
ducive to  pruritus;  the  same  is  true  of  tea,  coffee,  cocoa,  and 
strong  alcoholic  drinks.  Irregularity  in  eating  and  in  attend- 
ing to  the  calls  of  Nature,  by  causing  constipation  and  fecal 
impaction,  may  induce  pruritus  as  a  result  of  irritation  to  the 
nerves  and  obstruction  to  the  circulation  about  the  anus. 

Cutaneous  Affections  of  the  Ano-gluteal  region  are  not  uncom- 
mon, and  undoubtedly  are  frequent  causes  of  pruritus.  It  must 
be  remembered,  however,  that  they  may  be  secondary  to  the 
pruritus  and  a  direct  result  of  the  scratching  and  irritation  in- 
duced by  the  latter.  Pruritus  may  be  excited  by  an}^  of  the 
following  skin  diseases :  Erythema,  dry  or  moist  eczema,  ec- 
zema marginatum  (see  Dr.  Allen's  case,  Fig.  53 :  tinea  tricho- 
phytina  cruris),  erythrasma,  herpes,  prurigo,  scabies,  and, 
rarely,  psoriasis.  Of  these  the  most  common  is  anal  ringzvorm, 
or  tinea  circinata  cruris  (eczema  marginatum),  which  is  caused 
by  the  vegetable  parasite  trichophyton.  Again,  persistent  itch- 
ing of  the  anus  is  not  infrequently  caused  by  threadworms 
(oxyuris  vermicularis),^  pediculi,  and  other  parasites.  Sufficient 
importance  has  not  heretofore  been  given  to  threadworms  and 
other  parasites  as  a  cause  of  itching  of  the  anus. 

'  The  author  has  treated  eight  cases  of  pruritus  ani  due  to  thread  worms  ;  three  of  these 
were  adults  and  the  others  children  under  twelve  years  of  age. 


192  DISEASES  OF  THE  RECTUM  AND  ANUS 

Operations  About  the  Rectum  and  Anus,  where  the  wounds, 
have  not  entirely  healed,  leaving  a  more  or  less  extensive 
ulcerated  surface,  the  discharge  from  which  keeps  the  parts 
excoriated,  are  not  uncommon  causes  of  pruritus.  After  most 
rectal  operations  there  is  a  temporary  itching  about  the  anus; 
but,  if  the  wound  refuses  to  heal  and  ulceration  becomes 
chronic,  a  persistent  pruritus  results,  which  may  resist  treat- 
ment even  after  the  ulcers  have  healed. 

Diseases  in  Neighboring  Organs  accompanied  by  discharges 
which  find  their  way  to  the  rectum  or  the  skin  of  the  ano- 
gluteal  region  and  produce  excoriations  may  be  set  down  as 
occasional  causes  of  pruritus.  Again,  the  itching  may  be  one 
of  the  many  reflex  phenomena  of  disease  in  the  uterus,  ovaries, 
tubes,  vagina,  bladder,  urethra,  prostate,  testicles,  or  seminal 
vesicles,  or  it  may  be  due  to  interference  with  the  circulation 
by  disease  in  these  organs. 

Diseases,  More  or  Less  Systemic  in  character,  which  some- 
times cause  or  aggravate  pruritus  are:  rheumatism,  gout, 
malaria,  uremia,  Bright's  disease,  diabetes,  auto-intoxication, 
tuberculosis,  and  syphilis. 

Additional  Rare  Causes  of  pruritus  are  pederasty,  unclean- 
liness,  excessive  sexual  indulgence,  diseases  of  the  brain  and 
cord,  mental  distress,  neuralgia,  intestinal  fermentation,  preg- 
nancy, hypersensitiveness,  and  atrophic  changes  of  the  skin 
about  the  anus  in  old  age.  Other  causes  of  more  common 
occurrence  are  horseback-riding,  improper  or  printed  toilet- 
paper,  and  coarse  or  poorly-dyed  flannel  underwear. 

The  changes  in  the  structures  in  and  about  the  anus  in 
cases  of  pruritus  ani  depend  upon  its  cause  and  the  length  of 
time  it  has  existed.  In  some  cases  when  seen  early  there  are . 
no  visible  signs  of  the  condition  in  either  the  mucosa  or  skin, 
but  in  cases  of  long  standing,  especially  in  elderly  people,  there 
is  little  difficulty  in  recognizing  the  disease  from  the  marked 
changes  in  the  mucosa  and  skin  of  the  ano-gluteal  region.  In 
the  beginning  of  pruritus  ani  of  nervous  origin,  whether  due 
to  disease  of  the  brain  or  cord,  a  neuritis  or  pressure  upon  a 
nerve  or  its  terminal  filaments,  there  are  no  external  evidences 
of  the  condition;  but,  as  it  progresses,  the  usual  irritation  of 
the  skin  induced  by  scratching  will  become  manifest.  In  the 
earlier  stages  of  pruritus  ani  due  to  ulceration  of  either  malig- 
nant, specific,  or  other  nature,  or  to  disease  accompanied  by 


PRURITUS  ANI 


193 


a  discharge,  the  skin  and  anal  mucous  membrane  appear  moist, 
somewhat  reddened,  and  sometimes  swollen  and  tender  to  the 
touch.  Later  on,  because  of  the  continued  irritation  by  the 
acrid  discharge  and  the  coincident  scratching,  excoriation  of 
the  parts  becomes  noticeable,  and  a  type  of  subacute  inflam- 
mation is  excited  in  the  radiating  folds  of  skin  about  the  anus, 
and  these  become  swollen  and  sometimes  edematous.  If  the 
discharge  be  not  now  arrested,  and  the  parts  not  kept  clean, 
it  cohects  between  the  swollen,  radiating  folds  and  decomposes, 
causing  increased  irritation  and  an  extension  of  the  inflamma- 
tion;  the  skin  then  becomes  thickened,  less  mobile,  and  has  a 


Fig.  53. — Eczema  Marginatum. 


doughy  feel.  During  this  time,  as  a  result  of  gradual  exfolia- 
tion of  the  epithelium,  the  skin  loses  its  pigment  and  assumes 
a  dead-zvhite  hue:  the  typic  parchment-like  appearance  so  fre- 
quently described.  Finally,  the  affected  area  may  include  the 
entire  ano-gluteal  region;  hypertrophic  changes  may  occur  in 
the  skin,  and  cauliflower-like  excrescences  may  spring  up,  or 
eczema  or  erythema  may  be  induced.  In  the  majority  of  cases, 
however,  the  skin  becomes  rigid,  thickened,  harsh,  white,  and 
glistening.  The  radiating  folds  of  skin  become  enlarged,  elon- 
gated, and  more  prominent,  and  appear  like  long  rays  extend- 
ing out  from  the  anus  in  every  direction.    The  terminal  nerve- 


194  DISEASES  OF  THE  RECTUM  AND  ANUS 

filaments  are  destroyed  or  compressed  as  a  result  of  the  inflam- 
mation and  induration,  and  consequently  there  is  diminished 
sensibility.  The  cutaneous  blood-vessels  are  also  involved  and 
constricted,  and  the  skin  is  therefore  deficiently  supplied  with 
blood.  In  the  author's  opinion,  this  partially  accounts  for  its 
abnormal  color.  The  microscopic  examinations,  made  by 
Webster,  of  tissue  removed  from  cases  of  pruritus  vulvae 
showed  a  slowly-progressing  fibrosis  affecting  chiefly  the  nerves 
and  nerve-endings,  some  fibers  of  which  were  remarkably  com- 
pressed or  destroyed.  There  is  every  reason  to  beHeve  that 
similar  changes  occur  in  the  structures  about  the  anus  in  cases 
of  pruritus  ani.  As  a  result  of  continuous  irritation,  the  mu- 
cous membrane  becomes  thickened,  indurated,  and  less  mobile, 
and  sometimes  ulcerated  or  fissured.  When  the  parts  are  ex- 
amined by  the  finger,  there  is  a  sensation  of  roughness  and 
rigidity  along  the  entire  anal  canal,  and  in  cases  of  long  stand- 
ing in  the  aged,  accompanied  by  atrophic  changes,  long,  deep 
fissures,  passing  well  up  into  the  rectum,  may  be  found  between 
the  hypertrophied  radiating  folds  of  skin  about  the  anus.  As 
a  rule,  the  sphincter-muscle  becomes  slightly  hypertrophied  in 
cases  of  pruritus  ani,  but  in  exceptional  cases  the  anus  becomes 
somewhat  patulous.  In  rare  instances  the  itching  area  may 
extend  to  the  vulva,  or  scrotum  and  under-surface  of  the  penis, 
the  skin  of  which  becomes  raw  from  scratching. 

Marginal  eczema  (Fig.  53)  causing  pruritus  ani  retains 
many  of  the  characteristics  of  ringworm  in  other  parts  of  the 
body,  but,  owing  to  the  moisture,  which  favors  the  parasite, 
and  the  irritation  from  walking,  the  skin  is  more  highly 
colored,  and  constantly  moist.  The  circular  boundary  of  the 
involved  area  is  elevated,  highly  inflamed,  and  may  spread  to 
the  vulva,  or  to  the  scrotum  and  under-surface  of  the  penis. 
In  these  cases  microscopic  examination  will  reveal  the  pres- 
ence of  the  trichophyton. 

SYMPTOMS   AND   DIAGNOSIS 

In  pruritus  ani  the  symptom  which  is  more  marked  than 
all  others  and  which  causes  the  most  distress  is  intense  itching 
at  the  anus,  which  is  increased  by  the  moisture,  warmth,  and 
contact  of  the  buttocks.  Victims  of  this  affection  frequently 
complain  that  the  itching  is  so  harassing  that  it  is  more  diffi- 
cult to  endure  than  acute  pain,  and  that  life  is  rendered  almost 


PEUEITUS  ANI  195 

unbearable  by  it.  This  itching  is  usually  more  or  less  constant, 
but  grows  more  intense  after  the  patient  becomes  warm  in  bed 
at  night.  It  is  not  always  hmited  to  the  margin  of  the  anus, 
but  may  be  found  radiating  from  it  in  all  directions,  extending 
upon  the  scrotum,  down  the  limbs,  and  in  very  bad  cases  over 
the  coccyx  and  sacrum,  while  numerous  excoriations  and  fis- 
sures are  to  be  seen  as  a  result  of  scratching.  Only  temporary 
relief  from  the  itching  is  obtained  by  rubbing  the  parts,  yet 
few  can  resist  the  impulse  to  do  so,  even  though  experience 
has  taught  that  scratching  only  renders  suffering  the  more 
difficult  to  bear  on  the  morrow.  Many  patients  are  unable  to 
obtain  rest  for  several  nights  at  a  time,  and  when  they  drop 
off  to  sleep  they  unconsciously  scratch  until  the  parts  are  raw, 
thus  increasing  the  irritation  and  excoriation.  Some  sufferers 
are  so  harassed  by  the  itching,  rawness  of  the  parts,  and  pain 
caused  by  walking. that  they  are  unfitted  to  attend  to  either 
business  or  social  duties.  Stout  persons  and  those  who  per- 
spire freely  suffer  more  from  the  itching  because  of  greater 
irritation. 

Pruritic  subjects,  especially  those  who  are  chronically 
afflicted,  are  nervous,  irritable,  discouraged,  and  melancholic.  In- 
deed, many  of  them  assert  that,  if  relief  is  not  soon  obtained, 
they  will  end  their  sufferings  by  suicide. 

In  persistent  cases  of  pruritus  ani  the  skin  about  the  anus 
undergoes  a  marked  change  in  appearance.  The  divergent 
folds  of  skin  become  hypertrophied,  indurated,  roughened,  and 
elongated,  extending  from  the  anus  in  every  direction ;  the 
spaces  between  the  folds  become  fissured ;  the  skin  of  the  ano- 
gluteal  region  is  constantly  moist,  and  is  bleached,  dead-zvhite 
in  color,  glistening,  and  parchment-like.  Allingham  considers 
this  appearance  the  pathognomonic  sign  of  pruritus  ani.  The 
excoriations  appear  as  slight  chafing,  small  superficial  ulcers 
where  the  nails  have  torn  out  small  pieces  of  skin,  or  as  long, 
irregular  raw  marks  caused  by  the  scratching.  In  some  cases 
the  anus  may  become  infundibuliform. 

Cutaneous  affections, — such  as  eczema,  erythema,  etc., — ■ 
which  cause  pruritus  or  are  secondary  to  it,  are  easily  recog- 
nized by  their  resemblance  to  the  same  diseases  in  other  parts 
of  the  body.  When  marginal  eczema  is  suspected,  microscopic 
examination  should  be  made,  and,  when  the  fungus  (tricho- 
phyton) is  found,  the  diagnosis  will  be  affirmed.    The  readiness 


196  DISEASES  OF  THE  RECTUM  AND  ANUS 

with  which  the  superficial  structures  involved  in  pruritus  ani 
can  be  inspected  and  the  very  characteristic  symptoms  of  the 
disease  render  diagnosis  easy.  It  should  be  remembered,  how- 
ever, that  pruritus  ani  is  nearly,  if  not  always,  a  symptom  of 
some  constitutional  derangement;  of  local  disease  of  the  colon, 
sigmoid,  rectum,  and  anus ;  or  of  a  skin  affection  in  the  ano- 
gluteal  region.  Therefore  the  patient  must  be  closely  ques- 
tioned and  a  thorough  examination  made  in  order  to  ascertain 
and  locate  the  exact  cause  of  the  irritation.  Much  information 
is  to  be  gained  from  examining  the  urine  for  sugar  or  uric  acid 
in  excess,  because  pruritus  ani  is  so  frequently  caused  or  com- 
plicated by  diabetes,  rheumatism,  gout,  etc. 


CHAPTER  XIII 

TREATMENT  OF  PRURITUS  AN  I 

The  cause  of  the  irritation,  if  it  can  be  determined,  should 
be  removed  or  corrected  when  possible.  If  no  local  cause  for  the 
condition  is  evident,  but,  on  the  contrary,  the  patient  is  debili- 
tated, anemic,  or  neurotic;  or  has  a  rheumatic,  gouty,  tuber- 
cular, or  syphilitic  diathesis;  or  is  sufifering  from  Bright's 
disease,  diabetes,  obstructive  diseases  of  the  liver  or  heart, 
malaria,  neuralgia,  constipation,  or  auto-intoxication,  he  should 
receive  a  thorough  course  of  treatment  for  such  disease.  The 
treatment  of  disease  in  other  organs  which  directly  or  indirectly 
cause  or  influence  the  pruritic  condition  should  not  be  over- 
looked. When  the  itching  is  due  to  threadworms,  a  few  copi- 
ous injections  of  salt-  or  lime-  water,  turpentine,  or  a  strong 
decoction  of  black-oak  bark  will  ordinarily  destroy  them ;  in 
very  obstinate  cases,  however,  santonin  and  other  anthelmin- 
tics in  liberal  doses  are  necessary.  Any  disease  of  the  colon, 
sigmoid,  rectum,  or  anus — such  as  atrophic  or  hypertrophic 
proctitis,  hemorrhoids,  fissures,  ulcerations  of  all  kinds,  vege- 
tations, polyps,  procidentia,  stricture,  fistula,  or  gonorrhea — 
which  causes  or  aggravates  the  pruritus  must  be  treated  and 
corrected  by  surgical  or  other' means  before  the  treatment  for 
the  permanent  relief  of  the  itching  is  undertaken.  In  the  mean- 
time the  patient  should  be  made  as  comfortable  as  possible  by 
local  applications  to  allay  the  itching.  One  sliould  bear  in  mind 
that  surgical  or  palliative  treatment  of  local  disease  of  the  bozvel 
accompanied  by  pruritus  ani  frequently  fails  to  relieve  the  latter 
because  (a)  the  pruritus  is  either  of  systemic  origin  or  (b)  where 
the  itching  is  a  direct  residt  of  a  local  disease  zvhich  has  been  cor- 
rected, the  anal  mucosa  and  the  skin  of  the  region  have  become  so 
affected  that  independent  treatment  is  required  to  relieve  the  con- 
dition. 

The  treatment  of  pruritus  ani  is : — 

1.  Non-operative.  2.  Surgical. 

(197) 


198  DISEASES  OF  THE  RECTUM  AND  ANUS 

The  non-operative  treatment  consists  in; — 

1.  Regulating    the    habits,       5.  Inducing  rest  and  sleep. 

diet,  and  stools.  6.  Keeping   the   patient   in 

2.  Cleanliness.  the    recumbent    posi- 

3.  Protection  of  the  excori-  tion. 

ated  parts.  7.   Removing     or     treating 

4.  Reheving  the  itching  by  vegetations. 

mechanic  means.  8.  Local  applications. 

Regulating  the  diet  and  habits  of  the  patient  is  always  im- 
portant in  the  treatment  of  pruritus  ani.  Strong  drink  should 
be  prohibited.  Tea,  coffee,  and  cocoa  should  be  partaken  of 
sparingly.  A  light  diet — such  as  bread,  milk,  eggs,  nourishing 
soups,  koumiss,  and  a  limited  amount  of  fresh  fish,  broiled 
steak,  etc. — should  be  allowed.  Hot  cakes,  pastries,  parsnips, 
cheese,  pickles,  beans,  cucumbers,  cabbage,  oatmeal,  pork, 
shell-fish,  salmon,  lobster,  salt  fish,  confectionery,  and  starchy 
or  highly-seasoned  foods  are  to  be  interdicted.  Meals  must  be 
taken  at  regular  times;  lunches  between  meals  and  midnight 
suppers  must  be  stopped.  The  patient  must  avoid  overeating 
at  any  time.  The  author  has  frequently  observed  that  the  itch- 
ing is  aggravated  by  long  course  dinners  and  overindulgence 
in  highly-seasoned  foods  and  wines.  The  patient  should  obtain 
as  much  rest  as  possible,  and  have  regular  hours  for  sleep  and 
exercise. 

Regulating  the  stools  in  cases  of  pruritus  ani  must  not  be 
overlooked,  because  the  patient's  comfort  depends  a  great  deal 
upon  the  frequency  and  consistence  of  the  stools.  One  mod- 
erately-soft stool  should  be  secured  each  day,  if  possible.  Both 
liquid  and  hardened  stools  are  objectionable,  the  former  in- 
creasing tenesmus  and  the  latter  overstretching  the  anus.  To 
regulate  the  stools  in  frequency  and  consistence  there  is  noth- 
ing better  than  Carabafia  water,  3  ounces  (93  cubic  centime- 
ters) before  breakfast.  Where  the  feces  have  become  hard  and 
knotty,  2  or  3  ounces  (62  or  93  cubic  centimeters)  of  warm 
olive-oil  should  be  injected  into  the  rectum  shortly  before 
stool;  the  oil  not  only  lubricates  and  aids  the  passage  of  the 
fecal  masses,  but  it  is  also  soothing  to  the  bowel  after  their 
expulsion. 

Cleanliness,  both  of  the  rectum  and  ano-gluteal  region, 
should  be  closely  observed  in  these  cases,  because  discharges 


TREATMENT  OF  PRURITUS  ANI  199 

from  the  rectum,  those  forming  without  the  anus,  and  per- 
spiration, when  allowed  to  remain  in  the  cutaneous  folds  about 
the  anus,  intensify  the  itching  by  increasing  the  irritation  and 
excoriations.  The  parts  should  be  bathed  with  hot  water  or 
weak  solutions  of  carbolic  acid,  permanganate  of  potassium, 
borax,  bicarbonate  of  soda,  corrosive  sublimate,  alcohol,  or 
listerin,  the  heat  being  especially  soothing.  Bathing  the  parts 
with  bran,  oatmeal,  flaxseed,  salt,  rice,  slippery  elm,  or  tar- 
water  adds  much  to  the  comfort  of  these  patients.  Too  fre- 
quent washings  with  strong  soapy  waters,  so  highly  spoken  of 
by  some  writers,  are  to  be  discount enanced,  because  they  tend 
to  increase  the  irritation.  Hot  applications  applied  for  about 
five  minutes  also  act  beneficently  by  improving  the  absorptive 
power  of  the  skin.  When  the  skin  is  not  excoriated,  frequent 
applications  of  cold  water  exert  a  good  effect  by  promoting 
the  circulation. 

Protection  of  the  excoriated  parts  by  separating  the  but- 
tocks with  gauze,  a  thin  layer  of  cotton,  or  a  piece  of  soft  silk 
diminishes  itching  and  pain  by  absorbing  the  secretions  and 
preventing  irritation  while  walking. 

Relieving  the  itching  by  mechanic  means  proves  valuable  in 
some  cases.  The  patient  should  be  prohibited  from  scratching 
with  the  nails,  as  this  always  induces  hyperemia,  a  dermatitis, 
or  increased  excoriation  of  the  parts.  Relief  may  be  obtained 
by  making  direct,  firm  pressure  over  the  itching  area  with  a 
soft  cloth,  or,  as  Bronson  suggested,  by  drawing  a  well-oiled 
cloth  across  the  area  several  times.  Where  the  itching  is  so 
intense  as  to  prevent  sleep,  Allingham  advises  the  introduction 
of  a  bone  or  ivory  nipple-shaped  plug  into  the  anus  before 
going  to  bed.  He  claims  that  this  prevents  nocturnal  itching 
by  pressing  upon  the  venous  plexuses  and  terminal  nerve-fila- 
ments about  the  anus.  This  very  ingenious  little  instrument  is 
self-retaining,  about  two  inches  (5  centimeters)  in  length,  and 
as  thick  as  the  end  of  the  index  finger.  The  author  has  tried 
it  in  numbers  of  cases,  and  always  found  that  it  relieved  or 
palliated  the  itching. 

To  induce  rest  and  sleep  is  sometimes  absolutely  necessary, 
because  many  of  these  sufferers  toss  about  night  after  night, 
obtaining  but  little  sleep,  and  become  completely  exhausted. 
Morphine  and  opium  are  contra-indicated,  because  they  in- 
tensify the  itching  on  the  following  day.     Chloral  hydrate,  the 


200  DISEASES  OF  THE  EECTUM  AND  ANUS 

bromides,  sulphonal,  cannabis  Indica,  trional,  gelsemium,  and 
phenacetin  are  the  most  reliable  hypnotics.  Caution  is  neces- 
sary in  the  handling  of  these  remedies,  because  the  disease  is 
chronic,  and  the  patients  easily  become  slaves  to  them.  Co- 
caine or  eucaine,  applied  to  the  itching  area  in  the  form  of  a 
lotion  or  ointment,  sometimes  affords  much  relief. 

In  exceptional  cases,  where  the  excoriations  are  extensive 
and  the  parts  are  highly  inflamed,  the  patient  should  be  put 
to  bed  and  kept  on  his  back,  with  the  limbs  separated,  until  the 
irritation  has  been  allayed. 

When  vegetations  develop  as  a  result  of  the  constant  moist- 
ure, they  should  be  clipped  off  or  cauterized. 

Local  applications  of  every  description  have  been  used  in 
the  treatment  of  pruritus  ani ;  but  since  no  one  remedy  or 
combination  of  drugs  will  relieve  every  patient,  it  is  necessary 
to  change  them  to  suit  the  individual  case.  In  recent  and  in 
old  cases,  where  the  itching  is  intense  and  the  parts  are  acutely 
inflamed  and  excoriated,  soothing  remedies  are  indicated;  in 
aggravated  cases,  where  the  skin  is  thick,  indurated,  and  fis- 
sured, stimulating  or  cauterizing  agents  must  be  resorted  to. 
Among  soothing  remedies  may  be  classed  the  lead-and-opium 
wash,  boric  acid,  linseed-oil,  yucatol,  starch,  eucaine,  cocaine, 
and  zinc  stearate  with  boric  acid,  balsam  of  Peru,  or  acetanilid; 
zinc  in  this  form  is  especially  valuable,  because  it  adheres  when 
rubbed  upon  the  parts ;  a  very  nice  combination  with  which 
to  dust  the  parts  is  composed  of: — 

IJ  Boric  acid, 

Stearate  zinc   aa  3ij 

Talcum    3j 

M.     Sig.:    Apply  as  dusting-powder. 

The  writer  has  found  the  following  "hard  ointment"  a 
most  reliable  and  soothing  application  for  the  relief  of  ex- 
coriated surfaces : — 

U  Carbolic  acid  9j  13 

Menthol    gr.  x  65 

Camphor •  •   gr.  x  65 

Suet q-  ?.  ad  Sj  30 

M.     Sig.:    Apply  freely  two  or  three  times  daily  after  cleansing  the  parts. 

In  preparing  the  above  ointment,  melt  the  suet  and  when 
partially  cold  add  the  other  ingredients.    Do  not  add  oil,  as  the 


TREATMENT  OF  PRURITUS  ANI  201 

ointment  should  be  quite  hard,  the  object  being  to  form  a 
coating  over  the  parts  which  wih  not  be  penetrated  by  the 
secretions. 

The  following  glycerole  acts  nicely  in  some  cases : — 

IJ  Alum   gr.  vj        40 

Calomel     gi-.  xv    1 

Glycerin §j  30 

M.     Sig. :    Paint  over  excoriated  surface. 

At  St.  Mark's  Hospital,  London,  they  are  partial  to  the 
following : — 

IJ  Liq.  plumbi  subacetat.  (fort.) 3j  4 

Lactis    3vij       28 

M.     Sig.:    Apply  to  excoriated  parts  daily. 

Of  the  remedies  suggested  for  the  relief  of  itching  and  to 
stimulate  healing  of  the  excoriated  surfaces  are  the  following: 
Lotio  niger  (black  wash),  citrine  ointment  (unguentum  hy- 
drargyri  nitratis),  carbolic  acid,  ammoniated  mercury,  silver 
nitrate,  compound  tincture  of  green  soap,  chloroform  oint- 
ment, resorcin,  ichthyol,  balsam  of  Peru,  menthol,  chloral  and 
camphor,  and  dilute  sulphurous  acid,  etc.  The  most  useful 
combinations  are  the  following: — 

IJ  Carbolic  acid   3j  4 

Zinc  oxide    3j  4 

Glycerin    3iij        12 

Lime-water     gviij    240 

M.     Sig.:    Apply  once  or  twice  daily  to  relieve  the  itching  temporarily, 

R  Carbolic  acid  3j 

Calamin  prep 3ij 

Zinc  oxide    3iv         16 

Glycerin 3vj        24 

Lime-water    §j  30 

Rose-water    ad  Bviij   240 

M.     Sig.:    Keep  in  contact  with  the  itching  area  by  means  of  gauze  or 
cotton  while  the  itching  is  intense. 


R  Carbolic  acid S  j  1  j3 

Calamin  prep 9  ij  216 

Zinc  oxide    3j  4| 

Rose-water  ointment    ad  gij  601 

M.     Sig.:    Apply  freely  as  often  as  necessary. 


202  DISEASES  OF  THE  RECTUM  AND  ANUS 

IJ  Bismuth-oleate  ointment  (Morrow's) §j  301 

Carbolic  acid gtt.  x       j  65 

Menthol     9j  113 

M.     Sig. :    Use  in  and  outside  the  rectum  morning  and  night. 

IJ  Carbolic  acid  3  j  13 

Zinc  oxide    3j  4 

Gelanthum   Bij         60 

M.  Sig.:  Apply  to  skin  and  mucosa  two  or  three  times  daily  when  the 
itching  is  severe. 

As  stimulants  for  healing  deep  excoriations  caused  by  the 

scratching,  the  author  has  obtained  the  best  results  from  the 
application  of  silver  nitrate  (4  to  6  per  cent.),  ichthyol  (25  to 
75  per  cent.),  or  full-strength  balsam  of  Peru.  Of  these,  silver 
nitrate  has,  in  the  majority  of  cases,  been  found  to  be  the  most 
reliable.  These  solutions  should  be  painted  over  the  excoriated 
surface  two  to  four  times  a  week.  The  same  remedies  may 
be  applied  to  the  mucosa  when  excoriated,  although  the  injec- 
tion of  1  ounce  (30  grams)  of  the  following  solution  every 
night  after  the  bowel  has  been  emptied  will  prove  more  bene- 
ficial for  this  purpose : — 

^  Fluid  extract  of  krameria giv      120 

Biborate  of  soda 3is3         6 

Boric  acid 3j  4 

M.     Sig.:     Inject   one   ounce    (30   cubic  centimeters)   into  the  rectum. 

To  obviate  pain  from  these  or  other  medications,  3-per- 
cent, eucaine  or  4-per-cent.  cocaine  should  first  be  applied  over 
the  parts. 

For  excoriations  of  the  mucosa  Adler  recommends  the 
injection,  into  the  rectum,  of  3  drachms  of: — 

IJ  Fluid  extract  of  hamamelis Sj  30 

Fluid  extract  of  ergot 3ij  8 

Fluid  extract  of  hydrastis 3ij  8 

Compound  tincture  of  benzoin 3ij  8 

Carbolized  olive-  or  linseed-  oil  (carbolic  acid,  5  per 

cent.)    5j  30 

M.     Sig.:    Shake  well  before  using. 

Another  reliable  formula  for  the  same  purpose  is: — 

B  Ichthyol    3j  4| 

Olive-oil    5j  30| 

M.     Sig.:    Apply  to  mucosa  on  pledget  of  cotton. 


TREATMENT  OF  PRURITUS  ANI  203 

In  order  to  restore  the  circulation  and  transform  the  thick, 
indurated  skin  to  its  normal  color  and  suppleness  the  writer 
knows  of  no  better  remedy  than  citrine  ointment  (unguentum 
hydrargyri  nitratis).  After  the  parts  have  been  bathed  in  warm 
water  the  citrine  ointment  should  be  apphed,  thickly  spread  on 
a  piece  of  cotton  or  several  thicknesses  of  gauze  sufficiently 
large  to  cover  the  affected  area ;  this  dressing  is  covered  with 
oiled  silk  and  held  m  place  by  a  well-adjusted  T-bandage.  To 
obtain  the  full  benefit,  it  should  be  kept  on  constantly.  It  was 
through  the  suggestion  of  Dr.  Lewis  Adler,  of  Philadelphia, 
that  the  writer  was  led  to  employ  this  method  of  applying  the 
above  ointment.  In  some  cases  it  will  be  necessary  to  decrease 
its  strength  by  adding  lard,  and  in  others  it  must  be  used  on 
alternate  days  with  some  weaker  ointment,  such  as : — 

B  Calomel gr.  xx    1|3 

Vaselin    §j  30| 

M.     Sig. :     Apply   on   cotton. 

This  ointment  should  be  applied  in  the  same  manner  as 
the  citrine  ointment. 

In  cases  of  pruritus  ani  due  to  congenital  syphilis,  the  am- 
moniated  mercurial  ointment  has,  in  the  writer's  practice,  given 
the  best  results. 

In  obstinate  cases  of  pruritus  ani  Hyde  prefers : — 

U  Carbolic  acid  3iss  to  §ss  6-15 

Glycerin , 3ij  8 

Menthol    31  to  gss  4-15 

Rectified  spirit   q.  s. 

Distilled  water   q.  s.  ad  gviij  240 

•       M.     Sig.:    Apply. 

Unna's  ointment  is  especially  adapted  for  this  class  of 
cases.     Agnew  speaks  highly  of: — 

3  Carbolic  acid  gr.  xx     1 

Sulphur 3iij        12 

Citrine  ointment, 

Simple  cerate  or  lanolin aa  Ess         15 

M.     Sig.:    Apply. 

Mathews's  favorite  formula  in  cases  of  pruritus  ani  after 
the  scarf-skin  has  been  removed  is  composed  of: — 


204  DISEASES  OF  THE  RECTUM  AND  ANUS 

U  Menthol    3j  4 

Mur.  cocain gr.  xx     1 

Alcohol, 

Aquae  destiil aa  5j  30 

M.     Sig. :    Apply  on  cloth. 

Tuttle  relies  mainly  on  a  combination  of  carbolic  acid,  10 
to  20  per  cent. ;  salicylic  acid,  2  to  10  per  cent. ;  boric  acid,  5 
per  cent. ;  and  glycerin  or  cold  cream,  sufficient  to  make  100. 
All  of  the  tar  ointments  will  be  found  serviceable  in  eczema 
cases;   one  of  the  best  is  composed  of: — 

IJ  Ungt.  picis 3iij  121 

Ungt.  belladonnse  3ij  8 

Tinct.  aconiti 3ss  4 

Ungt.  aq.  rosse   3iij  121 

M.     Sig.:    Apply  freely. 

Much  reliance  can  also  be  placed  upon  the  following  com- 
bination : — 

IJ  Ungt.  picis 3j  4 

Zinc   oxide    3ij  8 

Ichthyol    3j  4 

Ungt.  aq.  rosas ad  5j  30 

M.     Sig.:    Apply  on  gauze. 

In  cases  of  eczema,  Dr.  Bulkley,  of  New  York,  recom- 
mends the  following,  after  cleansing  the  parts  thoroughly  with 
Castile  soap: — 

IJ  Liq.  carbonis  detergens    (Wright's) ,5j  301 

Glycerini     Bj  30j 

Pulvis  calaminse  prep 3ss  21 

Aquse     Svj  180| 

M.     Sig.:    Apply  daily  with  brush   and  allow  it  to  dry. 

Marginal  eczema  can  be  quickly  cured  with  a  few  applica- 
tions of  sulphurous  acid  or  with  six  or  eight  applications  of 
Wilkinson's  ointment,  viz. : — 

IJ   Sulphuris  sublimata, 
Picis  liquidse, 

Saponis  viridis    aa  3vj        241 

Terrse   albse    3iij        12J 

Adipis  suis  Bj  30[ 

M.  et  fiat  unguentum. 

Sig.:    Apply  to  excoriated  parts. 


TREATMENT  OF  PRURITUS  ANI  205 

This  remedy  causes  rapid  desquamation  and  the  formation 
of  new  skin.  In  very  obstinate  cases,  where  it  has  been  ad- 
visable to  remove  the  outer  layer  of  skin  quickly,  the  author 
has  employed  successfully  pure  carbolic  acid  or  the  Paquelin 
cautery. 

SURGICAL   TREATMENT. 

The  surgical  treatment  consists,  first,  in  the  removal  of 
any  existing  local  disease  that  would  be  likely  to  intensify  the 
itching,  such  as  ulcers,  hemorrhoids,  fissures,  polypi,  eczema, 
etc.  Thorough  divulsion  or  division  of  the  sphincter  and  a  few 
applications  of  silver  nitrate  to  fissures  and  ulcers  that  may  be 
present  will  nearly  always  cure  them,  and  thereby  relieve  the 
itching.  Where  no  local  disease  could  be  detected,  simple  divul- 
sion of  the  sphincters  has  given  relief  in  not  a  few  cases ;  the 
author  is  unable  at  present  to  state  why,  unless  it  was  due  to 
stretching  the  nerves.  In  one  or  two  cases  in  which  the  skin  was 
lacerated  for  a  considerable  distance  from  the  anus,  and  where 
it  failed  to  heal  after  the  sphincter  had  been  divulsed  and  the 
usual  remedies  tried,  an  anesthetic  was  administered  and  the 
diseased  parts  thoroughly  curetted  and  then  cauterized  with  a 
Paquelin  cautery-point.  The  raw  surface  left  was  treated  like  an 
ordinary  burn.  It  healed  kindly  in  a  short  time,  and  the  itching 
ceased,  proving,  in  the  writer's  opinion,  that  the  cause  of  the 
pruritus  was  within  the  skin  and  probably  of  parasitic  origin. 
The  author  has  on  two  occasions  resected  the  affected  skin  after 
Mathews's  plan,  with  only  partial  success,  and  he  believes  this 
operation  should  be  resorted  to  only  as  a  last  resource.  Many 
of  these  sufferers  will  wander  from  one  physician  to  another 
until  they  are  in  a  most  pitiable  condition  and  almost  beyond 
human  aid.  This  is  largely  their  own  fault,  for  many  become 
discouraged  and  seek  a  change  ere  the  physician  in  charge  has 
had  a  chance  to  do  the  patient  and  himself  j-ustice.  Even  in 
the  most  deplorable  cases,  with  due  care,  the  aid  of  surgery, 
lotions  and  ointments  judiciously  applied,  life  may  be  rendered 
bearable  and  a  cure  effected,  provided  they  surrender  them- 
selves entirely  to  the  physician's  care.  In  conclusion,  the  author 
wishes  to  state  that,  as  a  rule,  the  more  radical  the  treatment, 
the  quicker  the  patient  will  be  restored  to  health. 


206  DISEASES  OF  THE  EECTUM  AND  ANUS 

ILLUSTRATIVE  CASE 
Case  V.  Pruritus  Ani  (Aggravated  Case). — Ttie  case  in  point  was  that 
of  a  Frenchman  of  exceedingly  nervous  temperament  and  an  inveterate  smoker. 
The  itching  commenced  fifteen  years  ago,  but  of  late  had  become  so  intense 
that  he  was  unable  to  sleep  at  night.  He  suffered  much  during  the  day  from 
itching,  and  pain  where  the  skin  had  been  lacerated.  Like  all  who  suffer  from 
this  complaint,  he  had  tried  numerous  prescriptions  and  pile-ointments  recom- 
mended to  cure  it,  without  any  benefit  whatever.  He  said  that,  if  he  did  not 
soon  get  relief,  he  would  commit  suicide,  as  life  was  simply  unbearable.  On 
examination  I  found  the  skin  at  and  around  the  anus  thick  and  parchment- 
like; here  and  there  were  large  fissures  and  cracks,  produced  by  the  constant 
scratching.  Internal  examination  revealed  the  presence  of  a  large,  unhealthy 
ulcer  with  raised  edges,  and,  from  all  indications,  it  had  been  there  for  months, 
if  not  years.  I  ascribed  the  outer  condition  to  the  foul  discharge  fi'om  the  ulcer, 
and  determined  to  cure  the  same  before  trying  to  relieve  the  itching.  Accord- 
ingly, the  ulcer  was  curetted  and  incised  through  the  sphincter,  to  insure  rest. 
It  was  then  brushed  over  with  pure  nitric  acid,  and  he  was  placed  in  bed.  He 
progressed  nicely,  and  on  the  third  day  the  rectum  was  washed  out  with  car- 
bolized  water,  and  a  solution  of  silver  nitrate,  20  grains  (1.3  grams)  to  the 
ounce  (30  cubic  centimeters),  was  applied  to  the  ulcer.  In  addition  to  this,  I 
applied  Churchill's  tincture  of  iodine  over  the  itching  area  after  brushing  it 
over  with  a  6-per-cent.  solution  of  cocaine.  From  this  time  on  the  rectum  was 
cleansed  daily,  and  silver  nitrate  was  applied  both  to  the  ulcer  and  to  the 
itching  area  twice  a  week  for  three  weeks,  when  the  ulcer  had  completely 
healed.  The  applications  were  continued  to  the  outer  parts  one  week  longer; 
he  was  then  discharged,  the  itching  being  entirely  relieved. 


LITERATURE  ON  PRURITUS  ANI   (ITCHING  OF  THE 
ANUS,  ITCHING  PILES) 


Adler:     "Pruritus  Ani."     Paper  read  before  the  American  Protologic  Societv- 

1900. 
Agnew:    "Pruritus  Ani,"  "Rectal  Diseases,"  p.  176,  1896. 

Allingham:    "Pruritus  Ani,"  "Diseases  of  the  Rectum  and  Anus,"  p.  198,  1888. 
Andrews:    "Pruritus  Ani,"  "Rectal  and  Anal  Surgery,"  p.  137,  1892. 
Ball:    "Pruritus  Ani,"  "The  Rectum  and  Anus,"  p.  371,  1887. 
Cripps:    "Pruritus  Ani,"  "Diseases  of  the  Rectum  and  Anus,"  p.  275,  1890. 
Gant:    "Pruritus  Ani,"  "Reed's  Gynecology,"  p.  82.5,  1901. 
Heller:    "Ziemssen's  Cyclopedia,"  vol.  vii,  p.  752,  1876. 
Hyde:    "Pruritus  Ani,"  "Diseases  of  the  Skin,"  p.  750,  1900. 

"Eczema  of  the  Anus,"  etc.,  "Diseases  of  the  Skin,"  p.  384,  1900. 
Kelsey:  "Pruritus  Ani,"  "Diseases  of  the  Rectum  and  Anus,"  p.  450,  1890. 
Mathews:    "Pruritus  Ani,"  Mathews's  Med.  Quart.,  vol.  v,  p.  136,  1898. 

"Pruritus  of  Anus,"  "Diseases  of  the  Rectum  and  Anus,"  p.  493,  1896. 
Tuttle:    "Pruritus  Ani,"  Med.  News,  vol.  Ixxvi,  p.  1214,  1900. 
Van  Buren:    "Pruritus  Ani,"  "Lect.  on  Dis.  of  the  Rectum,"  p.  2,  1880. 
Webster:    "Pruritus  Vulvse,"  Trans.  Edinburgh  Oistet.  Soc,  1890-91. 


CHAPTER  XIV 

PROCTITIS    (RECTITIS,   CATARRH    OF   THE   RECTUM)    AND 
MEMBRANOUS   COLO=PROCTITIS 

Proctitis  is  an  inflammation  of  the  rectum  which  is  usu- 
ally confined  to  the  mucous  membrane,  but  may  extend  to  the 
deeper  structures.  Proctitis  is  acute  or  chronic.  Acute  proctitis 
may  be  catarrlial,  dysenteric,  diphtheritic,  gonorrheal,  or  erysipel- 
atous. Of  chronic  proctitis  there  are  two  varieties :  atrophic  and 
hypertrophic. 

ACUTE   PROCTITIS 

Etiology  and  Pathology.  —  Acute  inflammation  of  the  rec- 
tum may  be  induced  by  traumatism,  operations,  pathogenic 
bacteria,  exposure  to  cold  or  intense  heat,  impacted  feces,  mer- 
curial poisoning,  drastic  purgatives,  worms,  foreign  bodies  in 
the  rectum  (fish-bones,  pins,  grains  of  parched  corn,  etc.),  ir- 
ritating discharges  from  disease  in  the  colon,  careless  intro- 
duction of  the  syringe  in  giving  enemata,  intussusception,  pol- 
yps, prolapse  or  other  local  disease  of  the  rectum,  disease  of 
adjacent  organs,  use  of  strong  medicine  for  relief  of  rectal 
disease,  sodomy,  pederasty,  and,  in  children,  by  the  acrid  dis- 
charges and  tenesmus  accompanying  summer  diarrhea.  Again, 
it  may  be  due  to  the  specific  infection  of  dysentery,  diphtheria, 
gonorrhea,  cholera,  etc. 

In  acute  catarrhal  proctitis  the  mucous  membrane  of  the 
rectum  presents  an  appearance  similar  to  that  of  the  naso- 
pharyngeal mucosa  in  acute  coryza.  The  membrane  is  swollen, 
edematous,  highly  colored,  and  extremely  sensitive.  When 
mild,  the  inflammation  may  subside  and  the  membrane  be  re- 
stored to  its  normal  appearance ;  when  intense,  it  may  inter- 
fere with  the  circulation  and  result  in  sloughing  or  in  extension 
of  the  inflammatory  process  and  the  formation  of  abscess  in 
the  perirectal  tissues.  Again,  it  may  gradually  merge  into  the 
chronic  form  of  proctitis. 

In  dysenteric  (amebic)  proctitis  extensive  sloughing  of  the 
mucous  membrane  may  take  place,  causing  hemorrhage  and 
later  ulceration,  stenosis  of  the  bowel,  and  a  profuse  discharge 
composed  of  pus,  blood,  and  mucus. 

(207) 


208  DISEASES  OF  THE  RECTUM  AND  ANUS 

In  acute  proctitis  due  to  invasion  of  the  rectal  mucosa  by 
gonococci  the  membrane  is  thickened  and  bleeds  easily,  because 
of  the  chafed  condition  induced  by  the  discharge.  This  dis- 
charge is  copious,  thick,  yellow  in  color,  and,  owing  to  its  acrid 
qualities,  keeps  the  skin  of  the  ano-gluteal  region  constantly 
irritated. 

Diphtheritic  proctitis  is  a  result  of  systemic  poisoning,  and 
has  seldom,  if  ever,  been  encountered  except  as  a  secondary 
manifestation  of  diphtheria.  There  is  no  essential  difference 
in  the  formation  and  appearance  of  the  diphtheritic  membrane 
in  the  rectum  than  in  the  throat  and  nose.  Because  of  the 
difficulty  of  protecting  and  keeping  the  parts  clean,  extensive 
sloughing  and  ulceration  usually  occur,  and  death  soon  follows 
from  toxemia. 

Erysipelatous  inflammation  of  the  ano-rectal  region  is  ex- 
tremely rare,  and  the  pathologic  changes  caused  by  it  do  not 
differ  materially  from  those  seen  in  erysipelas  of  other  parts 
of  the  body. 

Symptoms  and  Dia^osis. — The  symptoms  of  acute  proctitis 
may  vary  according  to  the  nature  and  violence  of  the  attack. 
The  following  are  the  most  common  manifestations  of  this 
disease : — 

1.  Slight  elevation  of  temperature  and  accelerated  pulse. 

2.  Furred  tongue;  constipation  at  first  and  diarrhea  later. 

3.  Highly-colored,  swollen,  and  sensitive  mucous  mem- 
brane, which  is  sometimes  chafed. 

4.  Sensations  of  throbbing,  heat,  weight,  and  fullness  in 
the  rectum. 

5.  Constant  straining,  tenesmus,  and  frequent  discharges 
of  large  or  small  quantities  of  mucus,  blood,  and  pus. 

6.  Irritable  sphincter  and  spasmodic,  but  unsuccessful, 
attempts  to  relieve  the  bowel,  frequently  causing  the  mucous 
membrane  to  protrude. 

7.  Desire  to  micturate  often,  though  retention  sometimes 
occurs. 

8.  Burning,  heavy,  dull,  and  aching  pain  in  the  rectum 
and  reflected  up  the  back,  down  the  limbs,  and  to  neighboring 
organs. 

9.  Occasionally  sloughing,  ulceration,  or  extension  of  the 
inflammatory  process  to  the  perirectal  tissues  or  neighboring 
organs,  sometimes  resulting  in  abscess  and  fistula. 


PROCTITIS  209 

10.  Intense  pruritus  due  to  chafing  of  the  skin  and  mucous 
membrane  by  the  discharge. 

In  a  general  way,  acute  proctitis  is  analogous  to  localized 
inflammations  in  other  parts  of  the  gastro-intestinal  tract. 
Usually  it  lasts  from  one  to  three  weeks,  and  is  readily  amen- 
able to  treatment. 

Acute  proctitis  is  easily  diagnosticated  by  the  experienced 
proctologist,  but  is  frequently  overlooked  by  the  general  prac- 
titioner, for  the  reason  that  the  latter  usually  confines  his  ex- 
aminations to  the  lower  rectum  in  search  of  piles,  fissures,  and 
fistulas.  The  absence  of  a  history  of  previous  rectal  trouble, 
sudden  onset  of  burning  pain,  tenesmus,  profuse  muco-purulent 
discharge,  and  irritable  sphincter,  all  point  clearly  to  an  acute 
inflammation  of  the  rectum.  Reliance  should  not,  however, 
be  placed  upon  these  symptoms ;  on  the  contrary,  both  digital 
and  proctoscopic  examination  should  be  resorted  to  before  a 
positive  diagnosis  is  made.  If  this  condition  is  present,  digital 
exploration  will  reveal  the  state  of  the  sphincter-muscle,  tem- 
perature of  the  rectum,  and  tenderness.  Through  the  procto- 
scope may  be  noted  the  congestion  of  the  blood-vessels,  the 
highly-colored  and  thickened  or  chafed  mucosa,  and  the  char- 
acter of  the  secretions. 

Treatment. — When  the  disease  is  caused  by  a  foreign  body, 
impacted  feces,  or  local  disease  of  the  colon  or  rectum,  it  is 
essential  that  these  be  removed  or  corrected  before  measures 
are  adopted  to  relieve  the  inflammation.  Continued  rest  in  the 
recumbent  position,  regulation  of  the  bowels,  and  the  avoid- 
ance of  hard  and  indigestible  foods,  carbonated,  and  alcoholic 
beverages  should  be  insisted  upon.  A  diet  composed  of  milk, 
soft-boiled  eggs,  nourishing  soups,  and  albuminous  food  should 
be  rigidly  enforced.  Cold  or  heat  applied  constantly  over  the 
sacral  region  is  advisable,  and  the  rectum  should  be  continu- 
ously irrigated  with  warm  or  cold  water,  the  temperature  of 
which  may  be  changed  from  time  to  time  as  the  comfort  of 
the  patient  demands.  The  latter  can  be  accomplished  by  means 
of  the  Kemp  or  Barger  rectal  irrigator.  When  tenesmus,  pain, 
and  spasm  of  the  external  sphincter  become  unbearable,  suffer- 
ing can  usually  be  allayed  by  injection  of  a  few  ounces  of  an 
infusion  of  flaxseed,  warm  oil,  mixture  of  laudanum  and  starch- 
water,  or  by  the  insertion  of  a  suppository  containing  cocaine, 
or  belladonna  and  opium.     If  relief  does  not  follow  the  admin- 


210 


DISEASES  OF  THE  RECTUM  AND  ANUS 


istration  of  these  remedies;    the  sphincter  should  be  divulsed 
under  general,  or  divided  under  local,  anesthesia. 

As  the  violence  of  the  attack  subsides,  mild,  antiseptic, 
astringent,  and  stimulating  enemata  or  sprays  (Fig.  54)  should 
be  substituted.  The  most  reliable  of  these  are  permangan- 
ate of  potash  (1  to  3000),  corrosive  sublimate  (1  to  1000), 
carbolic  acid  (^ / ^  to  1  per  cent.),  alum,  zinc  sulphate  (1  per 
cent.),  copper  sulphate  (1  per  cent),  silver  nitrate  i^ / ^  to  1  per 
cent.),  hydrastis  (4  to  10  per  cent.),  boric  acid  (3  per  cent.), 
and  ichthyol  (1  to  2  per  cent.).  As  the  inflammation  is  allayed, 
the  strength  of  these  remedies  should  be  gradually  increased, 
depending  upon  the  ability  of  the  patient  to  bear  them  and  the 


Fig.  54. — Gant's  Set  of  Recto-colonic  Sprays.     Lengths:  6,  8,  10,  and  14  Inches. 
Can  be  Used  with  Hand-bulb  or  Compressed-Air  Tank. 

improvement  following  their  application.  Insoluble  powders 
should  never  be  used  in  the  treatment  of  acute  proctitis,  be- 
cause they  are  apt  to  accumulate,  cake,  and  act  as  an  irritant. 

Acute  rectitis  when  due  to  threadworms  is  soon  relieved 
by  a  few  injections  of  salt-water  in  conjunction  with  santonin 
internally. 

Acute  inflammation  will  occasionally  become  chronic  in 
spite  of  all  treatment. 


CHRONIC   PROCTITIS 

Chronic  proctitis  is  a  long-established  inflammatory  con- 
dition of  the  rectal  mucosa  which  sometimes  extends  to  the 
underlying  tissues.     It  is  met  with  more  frequently  in  adults 


PROCTITIS 


211 


than  in  children,  and  women  suffer  from  it  more  often  than 
men. 

Etiology  and  Pathology.  —  Chronic  proctitis  is  usually  sec- 
ondary to  the  acute  form,  and,  therefore,  may  be  indirectly 
induced  by  any  of  the  causes  enumerated  which  give  rise  to 
acute  inflammation  of  the  rectum.  This  condition  is  often 
caused  or  aggravated  and  prolonged  by  pederasty,  blind  in- 
ternal fistulas,  wounds  which  refuse  to  heal  after  rectal  opera- 
tions, and  by  secretions  from  syphilitic,  tubercular,  dysenteric, 
or   malignant   ulceration.      Proctologists   generally   recognize 


Fig.  55. — Hypertrophic  Proctitis,  Showing  Desquamated  Fatty  Epithelia,  Leu- 
cocytes, Calcium-Oxalate  Crystals,  and  Bacteria.  (Objective,  6;  ocular, 
iv;  Leitz.) 


two  varieties  of  chronic  proctitis,  namely :  Jiypertrophic  and 
atrophic. 

The  hypertrophic  variety  (Fig.  55)  may  begin  as  acute 
hypertrophic  proctitis,  and  is  frequently  of  syphilitic  origin. 
At  the  onset  the  mucous  membrane  is  highly  inflamed,  edem- 
atous, and  covered  by  an  abundance  of  thick,  tenacious  mucus 
containing  some  pus.  As  the  inflammation  proceeds,  the  mem- 
brane becomes  less  sensitive,  thickened,  and  less  pliable ;  the 
amount  of  pus-secretion  increases,  and  is  mixed  with  mucus 
and  blood. 

If  this  disease  be  allowed  an  uninterrupted  course,  it  re- 
sults in  the  formation  of  polypoid  excrescences,  or  in  stricture  due 


212  DISEASES  OF  THE  RECTUM  AND  ANUS 

to  an  increased  amount  of  fibrous  tissue  {proliferating  stenosing 
rectitis  of  Hamonic).  In  the  former  the  glandular  structures 
undergo  hypertrophic  changes,  due  largely  to  the  irritating 
secretions,  and  the  mucous  membrane  is  almost  covered  with 
papillomatous  vegetations  closely  resembling  condylomata. 
The  spaces  of  membrane  between  the  attachments  of  these 
growths  frequently  become  ulcerated. 

In  stenosing  rectitis  the  glands  atrophy,  and  the  mucosa, 
submucosa,  and  sometimes  the  muscular  fibers  undergo  fibroid 
degeneration,  resulting  in  partial  or  complete  annular  strictures, 
which  are  usually  single  and  situated  within  three  inches  (7.62 
centimeters)  of  the  anus.  Sometimes  stenosing  rectitis  and 
papillomatous  excrescences  are  present  in  the  same  case.  The 
vegetations  are  then  found  both  above  and  below  the  constric- 
tion. 

Two  other  forms  of  rectal  stricture  may  result  from 
chronic  proctitis :  (a)  tight  cicatricial  stricture,  and  (h)  long 
tubular  stricture  (Fig.  109),  due  to  inflammatory  exudations 
and  thickening  of  the  rectal  walls,  which  produce  narrowing, 
not  by  contraction,  but  by  encroaching  upon  the  lumen  of  the 
bowel. 

The  atrophic  proctitis  occurs  less  frequently  than  hyper- 
trophic, but,  like  it,  is  met  with  more  commonly  in  women  than 
in  men.  In  atrophic  proctitis  the  mucous  membrane  appears 
dry,  harsh,  and  dotted  over  with  small  fecal  scales  (Plate  XIV), 
having  the  appearance  of  smoking  tobacco.  The  mucosa 
is  not  so  highly  colored  as  in  the  hypertrophic  variety.  It 
cracks  easily  during  passage  of  the  feces,  and  through  the  proc- 
toscope blood  is  seen  oozing  from  many  minute  points  at  the  same 
time.     This  peculiar  condition  is  called  "pin-point  ulceration." 

The  slight  amount  of  mucus  secreted  contains  but  little 
pus,  tends  to  dry  up  quickly,  and  may  be  seen  clinging  to  the 
inner  surface  of  the  bowel  in  the  form  of  ball-like  masses,  large 
scales,  or  long  irregular  strips. 

The  skin  and  mucous  membrane  of  the  anal  region  are 
parchment-like  and  fissured,  resembling  the  condition  found  in 
pruritus  from  other  causes. 

Atrophic  proctitis  seldom  terminates  in  stricture. 

Proctitis,  acute  or  chronic,  is  not  limited  to  the  rectum, 
but  may  extend  to  the  perirectal  tissues,  resulting  in  abscess 
(periproctitis)  and  fistula. 


ULCERATING   PROCTITIS 


PROLIFERATING  PROCTITIS 
(Polyposis) 


ADENO-CARCINOMA 


ATROPHIC  PROCTITIS 


PLATE XIV.— Medullary  Adeno-carcinoma  of  the  Rectum  and  the  ditfereat 
forms  of  Proctitis  as  tbey  appear  through  the  proctoscope. 


PROCTITIS  213 

Symptoms  and  Diagnosis. — Chronic  proctitis  is  usually  pre- 
ceded by  the  acute  form,  but  its  symptoms  are  not  so  severe; 
there  is  less  pain  and  less  congestion  of  the  mucous  membrane, 
and  tenesmus  and  irritability  of  the  sphincter-muscle  are  much 
decreased.  The  stools  are  frequent  and  in  the  hypertrophic 
form  composed  principally  of  mucus  with  more  or  less  pus  and 
blood.  The  mucous  membrane  loses  its  pliability  and  sensi- 
tiveness and  may  be  covered  with  papillomatous  vegetations. 

In  other  cases,  because  of  fibroid  changes  in  the  lower 
rectum,  partial  or  complete  stricture  is  formed ;  the  patient 
suffers  from  constipation,  alternating  with  diarrhea,  almost 
constant  straining,  auto-intoxication,  and  pain  reflected  up  the 
back,  to  the  bladder,  and  down  the  limbs.  When  there  is 
ulceration  at  or  above  the  constriction,  large  quantities  of  pus, 
blood,  and  mucus  collect,  which,  if  not  given  a  free  outlet, 
cause  abscess  and  fistula.  The  discharge  dribbles  from  the 
anus  and  produces  some  pain  and  a  persistent  pruritus.  In 
rare  cases  the  sphincter-muscle  becomes  worn  out.  causing 
incontinence  and  a  patulous  condition  of  the  anus. 

In  atrophic  proctitis  the  mucous  membrane  is  dry,  fissured, 
bleeds  easily,  but  slightly,  and  is  dotted  over  with  dry  particles 
of  fecal  matter.  Constipation  prevails ;  the  stools  are  hard, 
small,  and  nodulated,  and  may  contain  a  slight  amount  of  dried 
mucus.  The  pain  is  local,  interrupted,  smarting  in  character, 
and  is  slightly  increased  by  defecation. 

There  is  little  difficulty  in  making  a  diag-nosis  in  chronic 
proctitis  if  a  clear  history  of  the  case  is  obtained  and  a  thor- 
ough proctoscopic  and  digital  examination  is  made.  It  is  well 
I  o  remember  that  in  some  of  these  cases  the  mucous  mem- 
brane becomes  thickened  and  rigid,  and  in  consequence  the 
.rectum  is  not  inflatable. 

Prognosis. — In  acute  rectitis  the  prognosis  is  usually  good. 
In  the  chronic  atrophic  form  much  patience  and  time  are  re- 
quired to  effect  a  cure.  The  same  can  be  said  of  the  hyper- 
trophic form  when  seen  early,  but,  after  the  mucous  membrane 
has  become  studded  w4th  vegetations  and  the  rectum  is  oc- 
cluded, the  prognosis  is  extremely  grave.  Indeed,  many  of 
these  patients  linger  for  a  long  time,  and  finally  die  of  peri- 
tonitis or  exhaustion. 

Treatment.  —  The  treatment  of  chronic  proctitis  is  both 
non-operative  and  surgical.  i 


214  DISEASES  OF  THE  RECTUM  AND  ANUS 

Non-operative  Treatment. — After  correction  or  removal  of  any 
irritating  disease  or  foreign  body  in  the  colon  or  rectum  tend- 
ing to  aggravate  or  prolong  the  inflammation,  the  secretions 
and  excretions  should  be  regulated  by  giving  attention  to  the 
diet  and  habits  of  the  patient.  Antiseptic,  stimulating,  and 
cleansing  remedies  should  then  be  applied  to  reduce  the  in- 
flammatory process.  Much  depends  upon  diet.  The  patient 
should  avoid  cold,  acid,  carbonated,  and  alcoholic  drinks; 
greasy  and  highly-seasoned  food;  and  the  immoderate  use  of 
coffee  and  tea.  The  diet  should  consist  principally  of  eggs, 
milk,  cream,  nourishing  soups,  beef-extracts,  broiled  steak, 
oysters,  baked  potatoes,  boiled  rice,  matzoon,  and  koumiss. 
Any  of  these  foods  should  be  discontinued  if  they  prove  to  be 
a  source  of  irritation.  Fruits  and  vegetables  may  be  taken  in 
limited  quantity,  except  when  the  stools  are  frequent. 

To  prevent  and  diminish  fermentation,  the  subnitrate  and 
salicylate  of  bismuth,  magnesia,  prepared  chalk,  phosphate  of 
lime,  bicarbonate  of  sodium,  and  charcoal  in  liberal  doses  are 
always  reliable  remedies.  When  intestinal  antiseptics  have 
been  indicated  in  the  writer's  practice  he  has  found  the  follow- 
ing formulas  satisfactory: — 


3  Soft  elastic  capsule  with  enteric  coating. 


Pot.  permanganate gr.  j 

Sodii   sulphocarbolati    gr.  v 

M.     Sig. :     One  t.   i.   d.   one   hour  after   meals. 

IJ  Soft  elastic  capsule. 

Sodii   sulphocarbolati    gr.  v         130 

No.  30. 

Sig. :     One  t.   i.   d.   one-half  hour  after  meals. 

These  capsules  should  have  an  enteric  coating,  to  render 
them  insoluble  in  the  acid  secretions  of  the  stomach. 

IJ  Betanaphthol     3iv  161 

Salicylate  of  bismuth 3ij  SI 

M.  et  div.  in  chart.  No.  xxx. 

Sig.:    From  three  to  twelve  powders  in  twenty-four  hours.  (Bouchard.) 

B  Salol, 

Salicylate  of  bismuth aa  3iiss      101 

M.  et  div.  in  chart.  No.  xxx. 

Sig.:  One  powder  at  each  of  the  principal  meals.     (Dujardin-Beaumetz.) 

When  a  laxative  is  necessary,  the  salines  or  any  reputable 
mineral  water,  such  as  Carabaha,  are  useful.     Strong  purga- 


PROCTITIS  •  315 

tives  are  always  contra-indicated.  When  there  are  frequent 
stools  due  to  dysentery,  ipecacuanha  in  large  doses  is  bene- 
ficial. 

To  reduce  the  inflammation,  encourage  the  heahng  of 
ulcers,  and  keep  the  bowel  in  a  proper  hygienic  condition,  the 
various  remedies  suggested  in  the  treatment  of  acute  proctitis 
should  be  used  by  enemata,  spray,  or  in  ointment,  but  in  much 
greater  strength.  The  greatest  benefit  is  derived  from  semi- 
weekly  enemata  of  silver  nitrate,  beginning  with  30  grains 
(2.6  grams)  to  the  pint  (473  cubic  centimeters),  to  be  grad- 
ually reduced  at  subsequent  treatments;  if  followed  by  pain, 
the  rectum  should  be  immediately  irrigated  with  physiologic 
(0.6  per  cent.)  salt  solution. 

Professor  Hare  recommends  the  repeated  injection  of 
about  2  ounces  of  saturated  solution  of  potassium  chlorate. 
Ulcers  which  refuse  to  heal  should  be  stimulated  by  touching 
with  the  silver-nitrate  stick,  nitric  acid,  or  the  thermocautery. 
The  writer  frequently  mops  the  mucosa  with  a  10-per-cent.  so- 
lution of  ichthyol  or  a  paste  composed  of  V2  drachm  (2  grams) 
of  bismuth  subnitrate  mixed  with  an  ounce  (30  cubic  centime- 
ters) of  balsam  of  Peru.  An  emulsion  composed  of  ^/s  ounce 
(15  grams)  of  bismuth,  ^/g  drachm  (2  grams)  of  iodoform,  and 
1  pint  (473  cubic  centimeters)  of  olive-oil  is  a  remedy  highly 
spoken  of  by  Prof.  J.  M,  Mathews.  Inject  3  ounces  (90  cubic 
centimeters)  biweekly. 

When  this  condition  is  due  to  syphiHs,  potassium  iodide 
is  indicated. 

To  relieve  pain  and  discomfort  the  patient  should  be 
requested  to  take  but  moderate  exercise  and  to  assume  the 
recumbent  position  as  much  as  possible.  Hot  hip-baths  are 
serviceable,  but,  when  much  pain  and  tenesmus  are  present, 
irrigation  and  intrarectal  medication  is  necessary.  Frequent 
irrigation  (Fig.  56)  with  hot  or  cold  water,  weak  carbolic- 
or  boric-  acid  solutions,  slippery-elm  water,  or  solutions  of 
hydrastis  (2  to  10),  borolyptol  (1  to  10),  listerin  (1  to  20),  or 
pinus  Canadensis  (1  to  8)  cleanse  and  soothe  the  rectum  and 
add  much  to  the  comfort  of  the  patient.  When  these  fail,  a 
suppository  of  opium  and  belladonna  should  be  used,  or  a 
mixture  of  mucilage  of  starch  and  a  sufficient  quantity  of  lau- 
danum should  be  thrown  into  the  rectum  to  allay  the  pain. 
Most  of  the  remedies  for  the  treatment  of  chronic  proctitis 


216  DISEASES  OF  THE  RECTtHNI  AND  ANUS 

may  be  easily  and  quickly  applied  in  ointment  form  by  means 
of  the  author's  recto-colonic  ointment  syringe  (Fig.  105). 

This  condition  being  of  a  chronic  nature,  it  is  necessary 
to  observe  caution  in  the  administration  of  opiates. 

Surgical  Treatment  should  not  be  resorted  to  in  cases  of 
chronic  proctitis  until  less  radical  measures  have  failed.  When 
the  sphincter  becomes  hypertrophied  or  irritable,  it  should  be 
thoroughly  divulsed  or  cut.  Ulcers  which  refuse  to  heal 
should  be  curetted  and  cauterized;  polypi  should  be  snared 
or  ligated  and  cut  off.  Vegetations  require  to  be  scraped  off, 
or,  better  still,  removed  by  clipping  them  from  the  mucosa  to 
which  they  are  attached ;  when  they  are  so  numerous  that  this 
is  impracticable,  an  artificial  anus  should  be  made;  the  bowel 
can  then  be  medicated,  kept  clean,  and  set  at  rest.  When 
there  is  complete  or  partial  occlusion,  the  stricture  must  be 


Fig.  56. — Dr.  R.  C.  Kemp's  Rectal  Irrigator,  New  Model.  Outer  Tube,  Hard 
Rubber;  Central  Tube  of  Metal.  Hard-Rubber  Flange,  Protecting  Sphinc- 
ter from  Transmission  of  Heat  Through  the  Metal  Parts. 

divulsed,  incised  internally  (internal  proctotomy),  or  poste- 
riorly, the  incision  being  carried  down  through  the  anus  (ex- 
ternal proctotomy).  When  these  operations  fail,  a  permanent 
artificial  anus  should  be  made  in  the  left  iliac  region  (inguinal 
colostomy).  In  exceptional  cases  of  chronic  proctitis  compH- 
cated  by  both  papillomatous  excrescences  and  stricture,  noth- 
ing short  of  extirpation  of  the  aft'ected  part  of  the  bowel  gives 
any  hope  for  the  future. 

MEMBRANOUS   COLO=PROCTITIS 

Synonyms.  —  Secretion  neurosis  of  the  colon  and  rectum; 
tubular,  fibrinous,  or  desquamating  colo-proctitis. 

Membranous  colo-proctitis  is  an  inflammation  of  the  colon 
and  rectum  peculiar  to  neurotics,  and  is  characterized  by  colicky 
pains,  soon  followed  by  the  discharge  of  large  quantities  of 
mucus  in  the  form  of  irregular  masses,  strings,   or  tube-like 


PROCTITlb 


217 


casts  (Fig.  57)  of  the  bowel.     It  is  extremely  rare  in  children, 
and  occurs  much  more  frequently  in  women  than  in  men. 

Authors  generally  agree  that  constipation  is  a  prominent 
etiologic  factor  in  cases  of  membranous  colo-proctitis.  In 
speaking  of  this  affection  Mathieu  says:  "It  is  a  superficial 
catarrhal  inflammation  of  the  large  intestine,  unassociated  with 
any  deep  lesion,  at  least  in  recent  cases.  It  is  probable  that 
the  desiccation  of  the  mucous  secretion  by  resorption  of  its 
water  gives  to  it  a  glutinous  and  then  a  membranous  aspect. 
However,  there  may  be  a  more  deeply  seated  inflammation, 
which  may  lead  even  to  ulceration,  becoming  then  an  inter- 


Fig.  57.— Membranous  Colo-proctitis,-  Showing  Membrane  Inclosing  Fatty  and 
Granular  Epithelia  and  Leucocytes.     (Leitz;  objective,  6;  ocular,  iv.) 


stitial  enteritis.  Wanebroucq  has  seen  cases  of  this  kind,  but 
the  name,  interstitial  enteritis,  certainly  applies  only  to  a  small 
number  of  severe  and  inveterate  cases  of  muco-membranous 
colitis.  It  is  probable  that  muco-membranous  enteritis  is  not 
a  morbid  entity,  but  that  it  may  depend  upon  various  etiologic 
factors.  However  this  may  be,  it  occurs  frequently  as  a  com- 
plication of  constipation." 

It  would  appear  that  constipation,  either  by  direct  or 
reflex  irritation,  excites  the  mucous  cells  to  hypersecretion, 
and  in  persons  suffering  from  chronic  constipation  this  over- 
secretion  may  become  a  part  of  the  Hfe  of  these  cells  and  be 


218  DISEASES  OF  THE  EECTUM  AND  ANUS 

extremely  difficult  to  combat.  The  author  has  seen  a  few  cases 
of  membranous  colo-proctitis  in  which  the  nervous  element 
seemed  to  be  secondary  to  an  antecedent  hypertrophic  proc- 
titis ;  the  patients  were  highly  nervous,  hypochondriac,  or  hys- 
teric over  their  condition. 

Byron  Robinson  has  so  graphically  described  the  character 
of  the  dejecta  and  the  appearance  of  the  bowel  in  this  condition 
that  the  writer  will  quote  him  verbatim: — 

"(a)  Macroscopically  the  evacuation  consists  of  membra- 
nous or  tube-formed  gray  masses.  They  may  resemble  mem- 
brane from  the  respiratory  passages  in  diphtheria.  The  mucous 
masses  may  be  transparent,  like  slime,  or  non-transparent,  like 
fibrin;  a  grayish  white  or  a  dirty  color,  with  pigment  in  it. 
Sometimes  the  masses  consist  of  large,  wide,  and  thick  leathery- 
like  membranes;  at  other  times  long  ribbon-like  bands  or  rope- 
like coils.  The  mucous  masses  are  nearly  always  alone,  un- 
mixed with  feces;  and  sometimes  they  resemble  the  swollen 
jackets  of  baked  potatoes.  By  careful  manipulation  in  water 
the  masses  of  slime  will  generally  unfold  into  membranes ; 
hence  the  term  'membranous  colitis.'  They  may  resemble 
fascias  or  tendons,  and  one  may  be  deceived  by  milk-coagula. 

"(b)  Microscopically  the  mass-substance  represents  a  hya- 
line body,  which  can  be  preserved  only  a  short  time  in  air, 
alcohol,  or  water.  Degenerating  cylindric  epithelia  of  almost 
any  grade  can  be  noted.  The  slimy  mass  represents  a  glassy, 
unformed,  transparent  substance,  and,  if  acetic  acid  be  added, 
it  assumes  a  wavy,  striped,  or  ground-glass  appearance.  The 
glandular  epithelia  are  almost  always  found  to  be  shrunken, 
swollen,  or  vacuolated.  Sometimes  vast  numbers  of  microbes 
are  present;  cholesterin  crystals,  triple  phosphates,  fecal 
masses,  pigment,  and  occasionally  round  cells. 

"(c)  The  Chemic  Examinations  reveal  mucin  or  mucin-like 
material  as  the  chief  constituent.  This  may  be  considered  as 
definitely  estabhshed,  as  it  is  confirmed  by  Clark,  Thomp- 
son, Perroud,  Da  Costa,  Hare,  Pick,  Nothnagel,  Fiirbringer, 
Hirsch,  Walter,  von  Jaksch,  Krysinski,  Kitagawa,  Rothman, 
Litten,  Vanni,  Leube,  and  Pariser:  a  sufficient  number  of  in- 
vestigators in  whom  to  confide.  Some  authors  assert  that 
mucin  is  the  chief  constituent,  with  other  albuminous  bodies. 
The  only  author  we  found  in  literature  who  claimed  that  fibrin 
existed  in  the  evacuations  of  secretion  neurosis  of  the  colon 


PROCTITIS  319 

was  p.  Guttman,  who  apparently  based  his  support  on  doubtful 
macroscopic  examination. 

"(d)  The  Pathologic  Findings  are  rare  on  account  of  the 
scarcity  of  material  on  which  to  establish  them.  Nothnagel 
reports  a  case  of  secretion  neurosis  of  O.  Rothman  which  was 
examined  by  C.  Ruge.  Ruge  reported  that,  'in  spite  of  careful 
examination  of  the  whole  intestinal  tract,  nothing  abnormal 
was  discovered.'  The  above  patient  of  Rothman  presented  a 
typic  picture  of  colica  mucosa,  but  died  from  duodenal  perfora- 
tion. O.  Rothman  had  another  case  who  died  of  carcinoma  at 
the  base  of  the  skull.  The  patient  was  in  the  hospital  from 
June  14  to  November  2,  1892.  By  giving  an  enema  the  patient 
evacuated  large  masses  of  mucus  without  pain.  He  had  no 
complaints  to  make  from  the  secretion  neurosis  of  the  colon. 
The  autopsy  showed  in  the  transverse  colon  (where  it  did  not 
contain  feces),  and  the  strongly  contracted  parts  of  the  de- 
scending colon,  injected  and  folded  mucosa.  Between  the 
folded  mucosa  were  products,  partly  membranous,  partly 
strand-formed.  The  parts  of  the  colon  filled  with  membrane 
contained  no  feces,  but  in  the  colon  ascendens  there  were  no 
mucous  masses,  but  feces  with  reddened  mucosa. 

"In  the  sigmoid  the  membranes  could  be  torn  from  the 
reddened  mucosa  without  loss  of  substance.  Feces  were  found 
in  the  small  intestine,  which  had  reddened  mucosa.  The  chief 
mucous  masses  were  found  in  the  left  half  of  the  transverse 
colon,  descending  colon,  and  sigmoid.  The  microscope  dem- 
onstrated the  mucous  masses  in  the  lower  colon  to  be  mucin, 
not  fibrin." 

A  condition  which  the  author  has  frequently  observed,  but 
has  not  seen  mentioned  elsewhere,  is  the  lodgment  of  tenacious 
mucus  above  the  "rectal  valves,"  which  induces  a  sensation  of 
drawing  and  weight  in  the  rectum.  When  the  "valves"  are  hy- 
pertrophied  and  stand  out  prominently,  considerable  mucus 
may  be  retained  above  them;  again,  when  the  mucus  is  te- 
nacious and  stringy  or  in  the  form  of  casts,  it  may  be  seen 
hanging  over  the  edges  of  the  "valves,"  and,  in  exceptional 
cases,  it  may,  when  abundant,  be  seen  extending  from  one  of 
the  upper  "valves"  downward  and  across  to  a  lower  one,  pre- 
senting, through  the  proctoscope  and  with  a  reflected  light, 
the  appearance  of  a  glass  partition  across  the  lumen  of  the 
bowel. 


220  DISEASES  OF  THE  RECTUM  AND  ANUS 

The  Symptoms  of  membranous  colo-proctitis  are  character- 
istic. The  attacks  are  irregular,  and  usuaUy  extend  over  a 
period  of  several  years,  but  very  rarely,  if  ever,  end  fatally 
unless  complicated.  These  patients  complain  of  a  sensation  of 
weakness  in  the  abdomen,  which  is  followed  shortly  by  colicky 
pains.  This  pain  is  continued  until  the  mucus  is  discharged. 
Mucous  discharges  which  are  soft  cause  less  suffering  than 
those  which  become  dry  while  adherent  to  the  mucosa.  The 
author  has  several  times  removed  enormous  scales  of  dried 
mucus  the  appearance  of  which  would  indicate  that  they  had 
been  retained  in  the  bowel  for  several  days  or  weeks,  during 
which  time  they  had  caused  much  suffering,  which  was  in- 
stantly relieved  by  their  removal.  With  the  exception  that 
these  patients  are  nervous,  most  of  them  feel  perfectly  well  in 
the  intervals  of  the  attacks.  In  many  of  the  cases  treated  by 
the  author,  while  the  pains  were  colicky-like  and  confined  to 
the  abdomen  at  first,  they  were  gradually  superseded  by  con- 
stant, heavy,  dull,  dragging-down  pains  located  in  the  lower 
sigmoid  and  upper  rectum ;  in  his  opinion,  these  agonizing 
pains  were  the  result  of  the  mucus  collecting  at  the  narrowest 
part  of  the  colon  (O'Beirne's  sphincter  at  the  recto-sigmoidal 
junction)  and  also  above  the  ''rectal  valves,"  and  at  the  point 
where  the  uterus,  when  retroverted,  presses  the  rectum  back 
against  the  bony  structures.  Frequently  when  the  accumula- 
tion of  mucus  is  considerable,  the  pains  may  be  reflected  up 
the  back,  to  the  bladder,  or  down  the  limbs.  Usually  the 
amount  of  suffering  is  in  direct  proportion  to  the  accumulation 
of  mucus,  though  in  rare  instances  considerable  mucus  may  be 
discharged,  having  caused  but  little  pain. 

Patients  suffering  from  membranous  colb-proctitis  often 
become  discouraged;  during  the  attacks  they  are  always  ex- 
tremely nervous,  and  obtain  but  little  rest. 

The  Treatment  of  this  affection  consists  in  overcoming,  as 
far  as  possible,  the  nervous  condition  of  the  patient  by  the  use 
of  arsenic,  strychnine,  and  like  drugs ;  in  relieving  the  consti- 
pation ;  in  correcting  the  diet ;  and  in  the  local  treatment  of 
the  bowel  by  means  of  irrigation,  sprays,  and  topic  applications. 
Castor-oil  in  moderate  doses  is  the  most  suitable  remedy  for 
the  purpose  of  securing  an  action ;  drastic  purgatives  are 
always  contra-indicated.  The  patient  should  consume  large 
quantities  of  water.    The  author  has  frequently  obtained  good 


PROCTITIS  231 

results  from  the  continued  use  of  olive-oil  in  dessertspoonful 
doses  (8  grams)  three  times  daily;  the  oil  not  only  produces 
stool,  but  also  acts  as  a  lubricant,  and  is  very  soothing  to  the 
mucosa  of  the  bowel.  Many  remedies  have  been  recommended 
as  injections  and  irrigants,  but,  in  the  writer's  hands,  those 
containing  olive-oil  and  some  antiseptic  have  proved  most  effi- 
cient. A  serviceable  enema  in  these  cases  is  composed  of  2 
drachms  (8  grams)  of  subnitrate  of  bismuth  and  V2  drachm 
(2  grams)  of  iodoform,  in  6  ounces  (180  grams)  of  olive-oil, 
to  be  shaken  and  injected  into  the  rectum  at  bed-time  and  re- 
tained as  long  as  possible.  Revilliod  speaks  highly  of  an  enema 
containing  2  '^ / ^  drachms  (10  grams)  each  of  subnitrate  and 
salicylate  of  bismuth  in  1  pint  (500  grams)  of  mucilage  of 
quince-seed. 

Oily  and  mucilaginous  injections  are  always  soothing,  and 
are  retained  for  a  longer  time  than  fluid  enemata.  In  order 
to  obtain  the  full  results  from  the  above  enemata  the  colon 
should  be  irrigated  with  hot  or  cold  water ;  mild,  antiseptic,  or 
astringent  solutions ;  or  starch,  or  flaxseed,  or  slippery-elm 
water  just  previous  to  their  injection. 

Sometimes  it  is  impossible  to  remove  the  accumulations 
of  mucus  above  the  "rectal  valves"  by  injections,  no  matter  how 
frequent  or  copious.  In  such  cases  the  author  has  succeeded 
in  removing  the  mucoid  collections  and  immediately  relieving 
the  patient's  suffering  by  introducing  the  proctoscope,  inflating 
the  rectum,  and  removing  the  mucus  from  above  the  "valves" 
after  pulling  the  latter  downward;  or,  when  the  mucus  is 
caught  at  the  recto-sigmoidal  junction,  by  twisting  it  about 
cotton  wound  around  the  end  of  a  long  applicator. 

During  the  attack  the  patient  should  be  kept  in  bed  and 
frequent  sitz-baths  given;  hot  stupes  should  be  applied  over 
the  abdomen  to  relieve  his  suffering.  When  it  is  desirable  to 
administer  an  internal  intestinal  antiseptic,  benzonaphthol  in 
10-grain  (60  centigrams)  doses  five  or  six  times  daily  is  the 
most  reliable.  Massage  and  electricity  are,  as  a  rule,  of  little 
service  in  these  cases ;  now  and  then,  however,  a  case  is  found 
which  is  improved  by  their  intelligent  application. 

It  is  also  necessary  to  improve  the  hygienic  surroundings 
of  these  patients  and  to  encourage  them  as  much  as  possible, 
for  many  of  them  are  despondent,  believing  their  disease  is  fatal 
and  that  they  have  but  a  short  time  to  live. 


223  DISEASES  OF  THE  RECTUM  AND  ANUS 

The  above  palliative  measures  usually  prove  effective  in 
relieving  membranous  colo-proctitis ;  but  it  frequently  requires 
several  weeks  or  months,  and  sometimes  years,  to  effect  a  cure. 

In  obstinate  cases  it  is  occasionally  necessary  to  resort  to 
surgical  procedures.  When  the  "rectal  valves"  are  hypertrophied 
and  prevent  the  discharge  of  the  mucus,  they  should  be  divided 
with  the  author's  "valvotomy"  clamp  as  described  in  the  chap- 
ter on  constipation.  Again,  in  cases  which  have  persisted  for 
years  in  spite  of  treatment,  nothing  short  of  the  establishment 
of  a  temporary  artificial  anus  will  effect  a  cure.  In  such  instances 
a  right  inguinal,  transverse,  or  left  inguinal  colostomy,  depend- 
ing upon  the  site  of  the  disease,  should  be  made,  and,  when 
possible,  the  opening  should  be  above  the  inflammatory  proc- 
ess. The  author  has  successfully  operated  upon  and  reheved 
three  cases  of  membranous  colo-proctitis  by  the  establishment 
of  a  temporary  artificial  anus;  in  two  the  opening  was  made 
in  the  sigmoid  colon  and  in  the  other  it  was  made  in  the  trans- 
verse colon  near  the  median  line.  The  openings  were  closed 
six,  fifteen,  and  twenty-two  months,  respectively,  after  the 
operations.  In  no  case  was  there  any  disturbance  in  the  func- 
tion or  atrophy  of  the  bowel  below  the  opening. 

Colostomy  hastens  a  cure  in  these  cases  (1)  by  permitting 
the  free  and  prompt  evacuation  of  the  feces  and  mucus,  thus 
avoiding  the  irritation  incident  to  their  accumulation;  (2)  by 
irrigation  the  bowel  can  be  kept  thoroughly  cleansed ;  and  (3) 
by  allowing  the  application  of  remedial  agents  directly  to  the 
affected  parts. 

Mayo  Robson,  in  1893,  reported  a  case  of  membranous 
colitis  which  he  cured  by  the  establishment  of  an  artificial  anus. 
Hale  White  and  Golding-Bird,  in  1895,  reported  a  similar  case. 
The  cases  mentioned  above  and  treated  by  the  author  were 
operated  upon  in  1896,  1898,  and  1900. 


LITERATURE  ON  PROCTITIS  AND  MEMBRANOUS  COIO-PROCTITIS 


Delbet:    In  le  Dentu  and  Delbet's  "Traite  de  Chirargie,"  vol.  viii,  1899. 

Einhorn:    "Diseases  of  the  Intestines/'  1894. 

Gant:    Kansas  Med.  Jour.  ("Monograph  on  Rectal  Disease"),  April,  1899. 

Golding-Bird:    Brft.  Med.  Jour.,  vol.  ii,  p.  1559,  1895. 

Hare:    College  and  Clinical  Record,  April,  1894. 


PROCTITIS  223 

Koenig:    "Lehrbuch  der  speciellen  Chirurgie,"  Bd.  ii,  1899. 

Le  Gendre:    "Muco-membranous  Colitis,"  Revue  Med.  de  la  Suisse  Romande  and 

Bulletin  Med.,  Jan.  29,  1893. 
Lyon,  G.:    Gazette  des  Hopltaux,  p.  493,  1889. 
Mathews:    "Diseases  of  the  Rectum  and  Anus,"  1896. 
Mathieu:    "Diseases  of  the  Stomach  and  Intestines/'   1894. 
Maylard:    "Surgery  of  the  Alimentary  Canal,"  p.  436,  1896. 
Nothnagel:    "Handbuch  d.  spec.  Pathologie  und  Therapie,"  xvii,  1898. 
Robinson:    "Secretion  Neuroses  of  the  Colon,"  Matheivs's  Med.  Quart.,  vol.  v, 

p.  47,  1898. 
Robson:   "Ulcerative  Memb.  Colitis,"  Trans.  Clin.  8oc.  London,  vol.  xxvi,  p.  213, 

1893. 
See,  Germain:     "Gastro-intestinal  Dyspepsia,"  p.  223,  1883. 
Talley:    Matheios's  Med.  Quart.,  vol.  v,  p.  28. 
Tuttle:    Ibid.,  vol.  i,  p.  7. 
Ziegler:    "Special  Pathological  Anatomy,"  American  edition,  1898, 


CHAPTER  XV 

PERIPROCTITIS    (ANO=RECTAL,  OR   ISCHIO=RECTAL, 
ABSCES5) 

Periproctitis  is  an  inflammation  of  the  perirectal  con- 
nective tissue,  which  usually  terminates  in  abscess-formation 
(commonly  called  ischio-rectal  abscess).  It  is  a  disease  seldom 
met  with  in  children,  occurring  most  frequently  in  middle-aged 
persons ;  men  are  affected  with  it  more  frequently  than  women, 
the  ratio,  in  private  practice,  being  about  five  to  one,  while  in 
dispensary  practice  the  proportion  is  even  greater.  Because 
of  diminished  resistance  due  to  poor  blood-supply,  the  loose 
perirectal  connective  tissue  is  one  of  the  most  frequent  sites 
of  inflammation. 

Etiology  and  Pathology.  —  Periproctitis  and,  secondarily, 
abscess  in  the  ano-rectal  region  may  be  due  either  to  exten- 
sion of  a  proctitis  or  to  external  influences.  Some  of  the  more 
common  causes  are :  sitting  on  cold,  damp  seats ;  horseback- 
riding;  foreign  bodies  in  the  rectum  (pins,  fish-bones,  etc.); 
stricture,  rupture,  or  traumatism  of  the  rectum  or  buttocks  by 
the  nozzle  of  a  syringe,  kicks,  falls,  or  punctured  wounds ;  in- 
fection following  rectal  operations;  and  superficial,  deep,  or 
perforating  dysenteric,  tubercular,  malignant,  syphilitic,  or 
chancroidal  ulceration.  Again,  a  perirectal  inflammation  may 
be  secondary  to  disease  in  the  Fallopian  tubes,  ovaries,  uterus, 
vagina,  bladder,  prostate,  seminal  vesicles,  or  urethra,  or  to  sup- 
puration of  Bartholin's  glands.  It  has  been  known  to  follow 
suppuration  of  pelvic  glands  and  caries  of  the  vertebra,  sacrum, 
coccyx,  or  pelvic  bones.  Other  causes  of  periproctitis  are  injury 
produced  by  the  passage  of  the  child's  head  during  parturition, 
subgluteal  and  psoas  abscesses,  dermoid  cysts  of  the  sacrum,  hip- 
joint  disease,  pyemia,  worms,  enteroliths,  typhoid  fever,  and 
puerperal  septicemia,  the  latter  being  a  common  cause  of  pelvi- 
rectal abscess. 

A  perianal  inflammation  resulting  in  marginal  abscess  is 
frequently  caused  by  fissures  or  suppurating  thrombotic  hem- 
orrhoids. In  rare  instances  there  occurs  a  fiirunculosis,  begin- 
ning in  the  follicles  about  the  anus.  These  collections  of  pus 
are  known  as  follicular  abscesses. 

Chronic  alcoholics ;  persons  who  are  overworked,  ema- 
(224) 


PERIPROCTITIS  225 

dated,  or  generally  run  down;  those  having  a  tubercular, 
gouty,  or  rheumatic  tendency;  and  syphihtic  subjects  are  fre- 
quently affected  with  perirectal  inflammation  and  abscess,  prob- 
ably owing  to  reduced  resistance  to  infection. 

Pyogenic  bacteria  are  always  present  in  the  terminal  colon, 
and  frequent  bruising  and  injury  to  the  mucosa  by  hardened 
feces  and  the  activity  of  the  pelvic  musculature  render  the  ano- 
rectal region  particularly  liable  to  infection  from  this  source. 
It  would  appear  that  the  infection  is  transmitted  through  the 
lymphatics  and  smaller  veins,  and  may  cause  abscess  in  the 
superficial  or  deep  structures  at  points  a  considerable  distance 
away  from  the  rectum. 

The  author  has  had  the  pus  from  a  large  number  of 
abscesses  of  the  ano-rectal  region  examined  microscopically. 
These  examinations  showed  that  the  bacteria  most  commonly 
found  in  these  abscesses  are,  in  the  order  of  their  frequency, 
the  bacillus  coli  communis,  streptococcus  pyogenes,  staphylo- 
coccus pyogenes,  and  tubercle  bacillus.  In  some  cases  two  or 
more  of  these  bacteria  were  found. 

Periproctitis  may  be  diffuse  and  extend  upward,  involving 
the  peritoneum,  and  downward  into  the  ischio-rectal  fossa  and 
perineum;  or  it  may  be  circumscribed  and  confined  to  a  small 
area  at  the  anal  margin.  The  inflammation  is  usually  of  the 
phlegmonous  type. 

When  the  inflammatory  process  is  followed  by  necrosis 
and  the  separation  of  enormous  sloughs,  it  is  called  gangrenous; 
when  it  begins  as  a  diffuse  inflammation  of  the  skin  and  rap- 
idly extends  in  all  directions,  it  is  designated  as  erysipelatous. 

Resolution  rarely,  if  ever,  takes  place  in  cases  of  active  peri- 
rectal inflammation,  and  it  is  only  a  question  of  time  until  an 
abscess  is  formed.  Abscesses  in  this  region  derive  their  names 
principally  from  their  location.  Those  most  commonly  en- 
countered are : — 

1.  Follicular.  3.  Intermural. 

2.  Marginal.  4.  Pelvi-rectal. 

5.  Ischio-rectal. 

Follicular  abscess  (furunculosis)  involves  the  follicles  about 
or  near  the  anus ;  marginal  abscess  (subcutaneous,  perianal)  is 
found  subcutaneously  at  the  junction  of  the  skin  and  mucous 
membrane;  intermural  abscess  (submucous)  occurs  between  the 


226  DISEASES  OF  THE  EECTUM  AND  ANUS 

mucous  membrane  and  muscular  coats  at  any  point  in  the 
rectum ;  pelvi-rectal  abscess  (periproctal)  occurs  above  the  leva- 
tor ani  muscle;  ischio-rectal  abscess,  which  is  by  far  the  most 
common  form  of  ano-rectal  abscess,  may  be  located  in  any 
part  of  the  ischio-rectal  fossa. 

SYMPTOMS 

The  manifestations  of  ano-rectal  abscess  are  variable,  and 
depend  upon  the  cause,  location,  size,  and  activity  of  the  in- 
flammatory process. 

Follicular  abscess  begins  with  itching;  later  there  are  slight 
soreness,  swelling,  and  inflammation  of  the  skin,  accompanied 
by  pain  resembling  in  every  respect  that  which  attends  a  boil 
elsewhere.  Marginal  abscess  is  usually  secondary  to  a  fissure 
or  suppurating  hemorrhoid;  it  appears  at  the  anal  margin  as 
a  small,  firm,  oval  tumor,  which  soon  breaks  down.  There  are 
slight  febrile  symptoms  and  constant  throbbing  pain,  which  is 
intensified  by  defecation  and  the  action  of  the  sphincter-muscle. 
Intermural  abscess  is  usually  preceded  by  ulceration  of  the  mu- 
cosa and  the  lodgment  of  some  small  foreign  body  beneath  the 
membrane.  In  its  onset  patients  complain  of  chilly  sensations, 
some  fever,  and  slight  pain  during  defecation;  later,  of  con- 
stant, dull,  aching  pain,  with  heat  and  fullness  in  the  rectum, 
which  increase  until  the  pus  finds  an  outlet  into  the  rectum. 

Pelvi-rectal  abscess  may  be  acute  or  chronic,  and  result 
from  extensive  rectal  operations,  pelvic  disease,  or  puerperal 
septicemia.  It  is  serious  from  the  beginning.  It  is  marked  by 
the  constitutional  disturbances  common  to  all  extensive  pus- 
formations.  The  pus  may  burrow  in  any  direction,  involving 
the  peritoneum,  or  open  into  the  bladder;  or  it  may  pass 
downward,  dissecting  its  way  between  the  levator  ani  muscles 
and  the  rectum,  and  find  an  exit  through  the  vagina  or  upon 
the  surface  in  the  ischio-rectal  region.  Again,  it  may  pass 
around  the  rectum  and  open  above  into  the  rectum  and  below 
through  the  skin  on  either  side  of  the  anus,  thus  forming  a 
horseshoe  fistula. 

Ischio-rectal  abscess  in  its  commencement  is  marked  by  a 
decided  chill,  followed  by  high  temperature,  quickened  pulse, 
furred  tongue,  loss  of  appetite,  constipation,  and  headache. 
Later  there  are  sensations  of  heat  and  fullness  in  the  rectum, 
constant  heavy,  throbbing  pain,  increased  by  defecation,  tenes- 


PERIPROCTITIS  227 

mus,  irritable  sphincter,  and  difficult  micturition.  The  infected 
area  is  rounded,  swollen,  firm,  and  very  tender,  and  the  skin 
over  it  is  reddened,  tense,  and  glistening.  As  the  disease 
progresses,  the  pus  forms  and  burrows  in  the  direction  of  least 
resistance,  and  may  point  in  the  rectum  or  upon  the  surface 
in  any  part  of  the  ischio-rectal  region,  where  fluctuation  may 
be  obtained.  Goodsall  says:  "The  weak  points  in  this  region 
are  (1)  the  interval  between  the  sphincters,  (2)  the  incomplete 
stratum  of  deep  fascia  separating  the  fat  of  the  fossa  from  that 
of  the  subcutaneous  tissue,  and  (3)  the  incomplete  attachment 
of  the  levatores  ani  to  the  ano-coccygeal  ligament." 

When  the  abscess  is  incised  or  the  skin  or  mucous  mem- 
brane gives  way  under  pressure,  the  pus  escapes  into  the  bowel 
or  upon  the  surface,  and  immediately  all  pain  and  febrile  symp- 
toms disappear. 

In  chronic  or  so-called  cold  abscesses  in  this  region  (espe- 
cially those  of  tubercular  origin  or  resulting  from  bone-necro- 
sis) the  inflammatory  process  is  not  so  rapid,  the  symptoms  are 
not  well  defined,  and  considerable  time  is  required  for  the  pus 
to  accumulate  and  make  its  presence  known. 

Ischio-rectal  abscesses  may  be  small  or  they  may  occupy 
the  entire  ischio-rectal  space.  When  anterior  to  the  anus,  they 
are  more  superficial  than  when  situated  on  either  side  or  poste- 
riorly. 

The  author  has  encountered  symmetric  ischio-rectal  ab- 
scesses situated  one  on  either  buttock,  and  which  had  no  com- 
munication. They  began  at  the  same  time,  and  were  alike  as 
to  location,  size,  and  appearance  (Fig.  58).  Apparently  they 
were  not  secondary  to  any  previous  ano-rectal  disease. 

The  abscess  may  open  into  the  rectum,  bladder,  vagina,  or 
urethra,  or  into  the  rectum  and  out  upon  the  labia  majora 
(labial  abscess),  or  upon  the  surface  of  the  skin;  or  it  may  com- 
pletely encircle  the  bowel  and  open  at  one  or  more  points  about 
the  anus.  In  the  majority  of  instances  the  opening  into  the 
rectum  will  be  found  posteriorly  at  the  junction  of  the  internal 
and  external  sphincter-muscles. 

The  pus  contained  within  these  abscesses  may  be  slight  or 
enormous  in  quantity;  it  is  thick,  yellow,  and  of  very  offensive 
odor;  that  from  tubercular  abscesses  is  thinner  and  whitish  in 
color. 

In  gangrenous  abscess  the  necrotic  process  may  involve  the 


228  DISEASES  OF  THE  RECTUM  AND  ANUS 

skin  and  deeper  structures  at  several  points.  Extensive  sloughs 
are  produced,  leaving  deep  cavities,  which  heal  slowly  and  are 
followed  by  troublesome  contractions. 

The  manifestations  of  erysipelatous  inflammation  of  the 
ano-rectal  region  do  not  differ  from  erysipelas  in  other  parts 
of  the  body. 

DIAGNOSIS 

The  diagnosis  of  the  more  common  forms  of  inflammation 
and  abscess  in  the  ano-rectal  region  is  not  difflcult. 

Follicular  abscesses  are  usually  multiple,  small,  cone- 
shaped,  movable  swellings  with  pus  pointing  in  the  center. 
They  are  situated  in  the  skin  near  the  anus  in  the  intergluteal 
region,  and  are  easily  recognized  because  of  their  close  resem- 
blance to  an  ordinary  boil.  Marginal  abscesses  are  ovoid 
swelHngs  somewhat  larger  and  less  movable  than  the  follicular 
variety.  They  are  extremely  sensitive,  and  are  situated  be- 
neath the  skin  and  mucous  membrane  of  the  anus,  frequently 
causing  an  eversion  of  the  membrane  and  bulging  of  the  skin. 
Intermural  abscesses  can  be  detected  only  by  digital  examina- 
tion. They  can  be  felt  projecting  into  the  rectum  as  fluctuating 
rounded  tumors ;  if  they  have  already  opened,  an  inflammatory 
area  is  left  from  which  pus  can  be  squeezed  with  the  finger. 

Pelvi-rectal  abscess  in  its  beginning  is  extremely  difficult 
to  diagnosticate,  because  of  its  location,  occasional  latency,  and 
its  advent  secondary  to  disease  of  adjacent  organs :  vertebra 
or  pelvic  and  hip-  bones. 

In  the  earlier  stages  of  deep-seated  ischio-rectal  abscess  a 
positive  diagnosis  can  be  made,  after  securing  a  history  of  the 
case,  by  palpating  the  rectum  and  deeper  structures  surround- 
ing the  anus.  With  the  index  finger  in  the  rectum  acting  as 
a  pivot,  the  perianal  structures  in  every  direction  should  be 
grasped  between  the  thumb  and  finger  until  the  inflammatory 
area  is  felt  as  a  firm,  rounded,  painful  swelling.  When  super- 
ficial or  when  much  pus  has  accumulated,  there  is  bulging  of 
the  skin,  which  is  glistening,  red,  and  inflamed,  and  fluctuation 
is  evident. 

PROGNOSIS 

The  prognosis  of  follicular  and  marginal  abscess  is  invari- 
ably good  when  they  are  properly  treated.  The  same  can  be 
said  of  the  intermural  and  ordinary  ischio-rectal  forms  in  so  far 


PERIPROCTITIS 


229 


as  life  is  concerned ;  but  they  sometimes  require  a  long  time 
and  several  operations  to  effect  a  cure;  in  exceptional  cases, 
where  they  communicate  with  adjacent  organs,  dangerous 
complications  may  develop.  The  prognosis  of  pelvi-rectal  ab- 
scess is  grave,  because  of  the  danger  of  death  from  peritonitis. 
Moreover,  it  leaves  adhesions  and  burrowing  sinuses,  which  are 
difficult  to  manage. 

In  gangrenous  periproctitis  and  abscess  the  prognosis  is 
even  more  grave  than  in  the  preceding  form,  and,  when  not 
promptly  arrested,  death  follows  either  from  extension  to  the 


Fig.  58. — Symmetric  Ischio-rectal  Abscesses.     (Author's  Case.) 


bladder  or  peritoneum,  or  from  septicemia  or  exhaustion.  The 
prognosis  of  erysipelatous  periproctitis  is  favorable  when  the 
disease  can  be  limited  to  a  small  area,  but  bad  when  it  cannot 
be  controlled. 

TREATMENT 

Very  little  can  be  accomplished  in  the  treatment  of  peri- 
proctitis and  ano-rectal  abscess  by  non-operative  measures.  In 
most  cases  periproctitis  terminates  in  abscess  in  spite  of  all 
treatment,  and  the  rules  governing  the  management  of  ab- 
scess in  other  parts  of  the  body  should  be  adhered  to  in  these 


230  DISEASES  OF  THE  RECTUM  AND  ANUS 

cases.  The  patient  should  be  made  as  comfortable  as  possible 
by  the  application  of  heat  or  cold,  rest  in  bed,  and  the  use  of 
mild  laxatives,  until  the  diagnosis  of  abscess  is  certain,  when 
the  swelling  should  be  freely  incised  without  delay.  The  author 
has  had  very  little  success  in  the  abortive  treatment  of  abscesses 
in  this  region  by  the  injection  of  solution  of  carbolic  acid  or 
other  remedies.  It  has  been  his  experience  that,  when  fluctua- 
tion is  present,  absorption  can  hardly  be  expected  to  take  place. 
In  his  opinion  it  is  far  better  to  incise  the  inflammatory  swell- 
ing and  fail  to  get  pus  than  to  procrastinate  and  allow  the  pus 
to  accumulate  and  burrow,  forming  single  or  multiple  fistulse. 
When  allowed  to  pursue  an  uninterrupted  course,  ano-rectal 
abscess  nearly  always  results  in  fistula,  because  of  the  frequent 
contractions  of  the  sphincter-muscle,  which  prevent  healing. 
When  properly  treated,  however,  it  seldom  termniates  in  fistula. 

xollicular  and  marginal  abscesses  should  be  injected  with 
sterile  water,  or  a  solution  of  eucaine  or  cocaine,  or  frozen  with 
the  ether-spray,  kelene,  or  liquid  air.  They  can  then  be  trans- 
fixed with  a  curved  bistoury  and  laid  completely  open  with  but 
little  pain.  They  should  then  be  irrigated  and  packed  with  anti- 
septic gauze. 

A  general  anesthetic  is  usually  necessary  for  operations 
upon  intermural,  ischio-rectal,  and  pelvi-rectal  abscesses.  After 
the  parts  have  been  thoroughly  cleansed  the  sphincter-muscle 
should  be  divulsed.  After  this  the  steps  of  the  operation  de- 
pend upon  the  form  of  abscess  to  be  dealt  with. 

When  the  abscess  is  of  the  submucous  variety,  a  bistoury 
is  guided  upward  in  the  rectum  by  the  index  finger  until  the 
most  prominent  part  of  the  abscess  is  reached,  when  it  is  freely 
incised  parallel  with  the  long  axis  of  the  bowel  to  avoid  the 
large  hemorrhoidal  vessels.  When  the  swehing  is  more  than 
three  inches  (Y.62  centimeters)  above  the  anus,  extreme  care 
should  be  taken  to  avoid  penetrating  the  peritoneal  cavity. 
Bleeding  is  usually  free,  and  it  is  necessary  to  pack  the  wound 
tightly  to  avoid  secondary  hemorrhage. 

The  operation  for  ischio-rectal  abscess  should  be  radical. 
The  operator  must  not  be  content  with  a  simple  puncture,  for 
evacuation  of  the  pus  in  such  a  condition  is  little  better  than 
no  treatment.  He  should  proceed  to  lay  the  abscess  wide  open, 
curette,  and,  if  necessary,  break  up  with  the  finger  the  various 
septa,  not  stopping  until  the  cavity  thus  produced  has  been 


PERIPROCTITIS  231 

completely  emptied  of  pus  and  necrotic  debris.  The  cavity 
should  be  thoroughly  irrigated,  and,  if  any  .unhealthy-looking 
tissue  still  remains,  it  should  be  cauterized  with  the  Paquelin 
cautery  or  with  pure  carbolic  acid,  the  action  of  the  latter  being 
controlled,  if  desirable,  with  95-per-cent.  alcohol.  When  the 
abscess  is  large,  one  or  more  counter-incisions  should  be  made 
at  right  angles  to  the  first  to  insure  free  drainage.  It  is  rarely 
necessary  to  waste  time  in  ligating  bleeding  vessels  unless  they 
are  large,  for  hemorrhage  will  be  arrested  when  the  wound  is 
packed. 

Pelvi-rectal  abscess  pointing  in  the  ischio-rectal  fossa  re- 
quires the  same  operation  as  one  having  its  origin  in  this 
locality.  The  sinus  leading  upward  from  it  should  be  curetted 
or  cauterized  with  carbolic  acid,  then  loosely  packed  with 
gauze  and  allowed  to  drain  through  the  incision.  In  excep- 
tional cases  it  is  best  to  approach  pelvi-rectal  abscesses  by 
laparotomy  or  through  the  vagina. 

In  these  operations,  unless  there  is  already  an  opening 
into  the  bowel,  the  incisions  should  not  extend  through  the 
sphincter,  because  of  the  danger  of  incontinence  and  a  prolonged 
convalescence.  At  the  primary  dressing  the  wound  should  be 
packed  tightly  with  gauze  to  prevent  hemorrhage. 

The  Post-operative  Treatment  is  of  the  greatest  importance. 
The  dressings  when  soiled  should  be  removed  and  the  wound 
irrigated  with  sterile  water,  antiseptic  or  stimulating  solutions, 
and  then  gauze  loosely  placed  in  the  bottom  and  in  every  corner 
of  the  sinus.  Care  should  be  taken  to  break  up  with  the  probe 
any  bridging  over  of  the  tissue  in  order  to  prevent  the  forma- 
tion of  sinuses.  Where  granulations  are  sluggish,  they  should 
be  stimulated  with  mild  solutions  of  silver  nitrate,  ichthyol,  bal- 
sam of  Peru,  or  other  stimulating  solutions.  When  they  are 
too  exuberant,  they  must  be  destroyed  with  stick  silver,  copper, 
or  acid. 

In  addition,  these  patients  should  have  nourishing  foods 
and  pleasant  surroundings,  and  remain  quietly  in  bed.  When 
necessary  they  should  have  codliver-oil,  malt,  iron,  hypophos- 
phites,  or  like  remedies.  When  indicated,  the  bowels  should 
be  regulated  with  Carabafia  or  other  reputable  mineral  waters. 


232  DISEASES  OF  THE  RECTUM  AND  ANUS 

LITERATURE  ON  ISCHIO-RECTAL  ABSCESS  AND  PERIPROCTITIS 


Burns:    Journal  Amer.  Med.  Assoc,  Feb.  25,  1899. 

Delbet:    In  le  Dentu  and  Delbet's  "Traite  de  Chirurgie,"  vol.  vii,  1899. 

Dennis:    "System  of  Surgery,"  vol.  iv,  p.  508,  1896. 

Duvall:    Georgia  Jour,  of  Med.  and  Surg.,  June,  1899. 

Garvin:    Louisville  Jour.  Med.  and  Surg.,  vol.  v,  p.  443,  1898. 

Goodsall  and  Miles:    "Diseases  of  the  Anus  and  Eeetum,"  Pt.  I,  p.  55,  1900. 

Koenig:    "Lehrbuch  der  speciellen  Chirurgie,"  Bd.  ii,  1899. 

Mathews:    Mathews's  Med.  Quarterly,  vol.  i,  p.  165,  1894. 

Mathieu:    "Diseases  of  the  Stomach  and  Intestines,"  1894. 

Maylard:    "Surgery  of  the  Alimentary  Canal,"  p.  580,  1896. 

Meisel:   Beitrdge  zur  kliniscJien  Chirurgie,  Sept.,  1900. 

Nothnagel:    "Handbuch  d.  spec.  Pathologie  und  Therapie,"  vol.  xvii,  1898. 

Pennington:    Chicago  Clinic,  vol.  xii,  p.  185,  1899. 


CHAPTER  XVI 

HISTORY,    ETIOLOGY,    PATHOLOGY,  AND   CLASSIFICATION 
OF  ANO=RECTAL   FISTULA 

This  chapter  very  naturally  follows  the  preceding  one,  be- 
cause rectal  and  anal  fistulas  are  usually  sequels  of  perirectal 
inflammation  and  abscess. 

The  term  "fistula"  is  derived  from  the  Latin  word  fistula, 
meaning  reed  or  pipe,  and  was  probably  applied  to  the  condi- 
tion under  discussion  because  of  the  existence  here  of  a  tube- 
like channel  through  which  gas  or  feces  may  escape  in  com- 
plete fistula. 

A  -fistula  in  ano  may  be  defined  as  an  unhealthy  or  non- 
granulating  sinus  with  two  openings,  one  upon  the  surface  of  the 
body  near  the  anus  and  the  other  in  the  rectum.  This  constitutes 
a  typic  fistula.  There  are  several  other  varieties  of  fistula  which 
will  be  described. 

Fistulas  occurring  about  the  rectum  and  anus  have  for 
hundreds  of  years  been  described  under  the  title  of  "fistula  in 
ano."  For  this  reason  the  designation  will  be  retained,  even 
though  it  would  be  more  scientific  and  expressive,  as  far  as  the 
location  of  the  lesion  is  concerned,  to  designate  those  fistulas 
opening  high  in  the  rectum  as  rectal  and  those  opening  just 
within  the  anal  margin  as  anal  fistulas. 

HISTORY 

Fistula  in  ano  was  accurately  described  by  Hippocrates, 
Celsus,  and  many  other  ancient  writers;  and  the  etiology  as 
given  by  them  holds  good  in  a  large  measure  to-day.  From 
the  time  of  Hippocrates  little  was  written  about  fistula  for  sev- 
eral hundred  years.  The  principal  reason  for  this  was  that 
persons  suffering  from  fistula  were  supposed  to  have  an  in- 
curable disease,  and,  in  ancient  times,  to  be  afflicted  with  such 
a  disease  was  a  disgrace.  Another  reason  why  this  disease  was 
not  seen  and  described  more  frequently  was  that  those  who  had 
it  would  not  submit  to  ocular  and  digital  examination.  Hume, 
in  his  "History  of  England,"  records  the  death  of  Henry  V, 
King  of  England,  in  1422.     He  says  that  the  king  was  seized 

(233) 


234 


DISEASES  OF  THE  RECTUM  AND  ANUS 


with  a  fistula:  a  malady  which  the  surgeons  of  that  time  had 
not  the  necessary  skill  to  cure.  Shakespeare  has  immortahzed 
fistula  in  his  play,  "All's  Well  that  Ends  Well,"  written  about 
1606.  Later,  John  Astruc,  in  his  Latin  thesis,  translated  into 
English  in  1728,  tells  that  this  disorder  sank  almost  into  ob- 
livion, and  was  scarcely  seen  or  heard  of  by  physicians  of  the 
day  until  Louis  XIV,  of  France,  suffered  from  it.  Then  the^ 
disease  at  once  became  fashionable,  and  a  vast  multitude  of 
cases  suddenly  appeared;  and,  after  the  king's  example,  every- 


Fig.  59.— A,  Complete  Fistula;  B,  Blind  Internal  Fistula. 


one  made  a  voluntary  and  open  confession  of  this  once  secret 
disorder.  Astruc  further  says  that  in  the  reign  of  Tiberius 
Caesar  the  disease  first  showed  itself.  No  man  in  Rome  ever 
complained  of  it  until  the  emperor  had  been  severely  attacked 
by  it.  It  is  stated  that  Louis  XIV  paid  Monsieur  Felix  and 
his  various  assistants  for  the  operation  the  enormous  sum  equal 
to  seventy-three  thousand  five  hundred  dollars. 

Any  person,  irrespective  of  nationality,  age,  sex,  climate, 
or  occupation,  may  suffer  from  ano-rectal  fistula.  This  com- 
plaint is  encountered  usually  in  middle  life  and  more  frequently 


ANO-RECTAL  FISTULA 


235 


in  men  than  women.  It  is  seldom  met  with  in  childhood.  The 
writer  treated  a  girl,  8  years  old,  in  whom  the  disease  was 
due  to  threadworms.  A  second  case  coming  under  his  ob- 
servation was  that  of  a  girl,  little  more  than  a  year  old,  where 
the  cause  was  a  pin  which  had  been  swallowed  and  lodged  in 
the  rectum.     Fistula  in  ano  is  a  very  common  affection;    in 


Fig.  60.— Types  of  Complete 
Fistula. 


Fig.  61.— Unusual  Types  of  Complete 
Fistula. 


fact,  it  occurs  with  greater  frequency  than  any  other  disease 
encountered  about  the  anal  region.  It  is  not  uncommon  in 
the  well-to-do,  but  is  met  with  more  frequently  in  people  living 
in  crowded  communities.  Out  of  16,060  cases  of  rectal  diseases 
treated  in  St.  Mark's  Hospital,  London,  from  1872  to  1891, 


\ 


J 


Fig.  62.— Unusual  Types  of  Blind 
Internal  B'istula. 


Fig 


63. — Common  Types  of  Blind 
Internal  Fistula. 


as  compiled  by  Cooper  and  Edwards,  8497,  or  a  little  more 
than  50  per  cent.,  were  treated  for  fistula  in  ano  in  some  form. 
Of  these,  5829  were  men,  and  2668  women.  This  is  about  the 
usual  percentage  as  regards  sex.  The  author  in  his  work  has 
not  found  that  fistula  occurs  as  frequently  as  all  other  rectal 
diseases  combined.     In  dispensary  practice  he  has  observed 


236  DISEASES  OF  THE  RECTUM  AND  ANUS 

that  about  one  person  in  three  has  fistula.  The  proportion  of 
fistulas  to  other  diseases  is  not  so  great  in  the  upper  circles 
of  society.  This  is  probably  due  to  the  fact  that  their  occu- 
pations are  not  so  arduous,  they  are  not  exposed  to  inclement 
weather,  and  do  not  live  in  densely-populated  districts  where 
tuberculosis  is  common. 

ETIOLOGY  AND   PATHOLOGY 

The  etiology  and  pathology  of  periproctitis  and  abscess 
do  not  differ  in  the  main  from  those  of  fistula  in  ano,  because 


Fig.  Si.— A,  Blind  External  Fistula;  B,  Complete  Internal  Fistula. 

the  latter  is  invariably  secondary  to  the  former.  An  abscess 
which  has  been  opened  or  allowed  to  rupture  seldom  heals 
spontaneously.  On  the  contrary,  it  gradually  shrinks  up  and 
degenerates  into  the  ordinary  fistulous  tract.  There  are  sev- 
eral reasons  why  perirectal  abscesses  do  not  get  well :  (a)  rest 
is  impossible  owing  to  the  acts  of  defecation  and  micturition 
and  the  activity  of  the  sphincters;  (b)  the  venous  circulation 
in  this  region  is  sluggish  by  virtue  of  the  upright  position  as- 
sumed by  man  and  the  lack  of  proper  support  to  the  veins  of 
this  region;    (c)  the  entrance  of  foul  gases  and  feces  into  the 


ANORECTAL  FISTULA 


237 


abscess-cavity  when  an  opening  into  the  rectum  exists ;  (d) 
retention  of  pus  when  the  openings  are  small;  (e)  when  due 
to  local  tuberculosis  the  destructive  process  is  prone  rather 
to  extend  than  to  heal. 

Except  when  due  to  a  pre-existing  rectal  disease, — such 
as  hemorrhoids,  fissures,  ulceration,  polyps,  stricture,  proctitis, 
and  malignancy, — fistula  in  ano  usually  occurs  in  persons  with 
a  debilitated  constitution  who  have  received  an  injury  either 


Fig.  65.— A,  Complete  External  Fistula;  B,  Recto-vaginal  Fistula. 


to  the  mucosa  by  the  passage  of  hardened  feces  and  foreign 
bodies  or  the  introduction  of  instruments,  or  to  the  buttocks 
from  external  violence.  In  this  class  of  cases  suppuration  is 
liable  to  occur  as  a  sequel  of  irritation  or  slight  bruising  of 
the  parts,  owing  to  the  ever-present  bacteria,  lowered  resist- 
ance, and  faulty  blood-supply  of  the  perirectal  connective  tissue. 
Dermoid  cysts  (page  491)  situated  over  the  sacrum  and  coccyx 
are   responsible   for   the   majority   of   fistulas    opening   above 


238 


DISEASES  OF  THE  EECTUM  AND  ANUS 


the  anus  in  the  posterior  median  Hne.  Tuberculosis,  beginning 
in  the  rectum  or  upon  the  skin,  is  a  frequent  cause  of  fistula 
in  the  ano-rectal  region.  Some  authors  contend  that  the 
formation  of  a  sinus  in  these  cases  is  not  always  preceded 
by  abscess:    views  not  in  harmony  with  those  of  the  writer. 

VARIETIES   OF  FISTULA 

There  are  several  varieties  of  fistula  named  from  their 
location,  number  of  openings,  and  the  organs  with  which  they 
communicate,  as  follows : — 


1. 

Complete. 

6. 

Horseshoe. 

2. 

Blind  internal. 

Y. 

Complex. 

3. 

Blind  external. 

8. 

Recto-vaginal. 

4. 

Complete  internal. 

9. 

Recto-vesical. 

5. 

Complete  external. 

10. 

Recto-urethral 

11.   Recto-labial  (vulvar). 


Fig.  66.— Complex  Horseshoe  Fistula  witli  Six  Openings  on  the  Surface,  One 
in  the  Rectum,  One  in  the  Vagina,  and  Two  in  the  Labia. 


Complete  Fistula  is  one  which  has  two  openings :  one  upon 
the  surface  of  the  body  in  the  neighborhood  of  the  anus  and 
the  other  in  the  rectum  (Fig.  59,  A ;  and  Plate  XVI).  It 
is  the  most  common  form  of  fistula.  The  openings  of  com- 
plete fistula  vary  as  to  location.  As  a  rule,  the  internal  open- 
ing is  situated  posteriorly  at  the  junction  of  the  external  and 
internal  sphincters,  though  in  not  a  few  cases  it  is  located  on 
either  side  higher  up.  The  external  opening  is  ordinarily  to 
be  seen  within  an  inch  (2.54  centimeters)  of  the  anus,  and  in 
many  cases  just  opposite  the  internal  opening.  Again,  the 
external  opening  may  be  quite  a  distance  from  the  anus  (Fig. 
60),  and  the  sinus  leading  from  the  external  to  the  internal 


ANORECTAL  FISTULA 


239 


opening  may  be  very  long  and  irregular  (Fig.  61)  and  have 
diverticula  leading  from  it  in  various  directions.  This  form 
of  fistula  constitutes  about  75  per  cent,  of  the  cases. 

Blind  Internal  Fistula  consists  of  a  sinus  without  an  external 
communication,  but  with  an  internal  opening  into  the  rectum 
(Fig.  59,  B).  While  not  so  common  as  the  complete  variety, 
one  who  treats  rectal  disease  as  a  specialty  will  meet  many 
such  cases,  and  will  find  them,  in  many  instances,  very  difficult 
to  diagnosticate.     The  sinus  may  have  its  origin  at  any  point 


Pig.  67. — Horseshoe  Fistula. 


in  the  ischio-rectal  fossa,  in  the  submucous  or  subcutaneous 
tissues,  and  its  course  may  be  in  any  direction  (Figs.  59,  62, 
and  63). 

Blind  External  Fistula  is  superficial,  and  usually  formed  from 
an  abscess  located  in  the  subcutaneous  tissues,  the  pus  from 
which  has  found  an  outlet  only  upon  the  surface  of  the  body. 
There  is  no  communication  with  the  rectum  at  all  (Fig.  64,  A), 
though  it  burrows  in  that  direction  if  not  operated  upon.  This 
form  of  fistula  is  very  rare,  being  less  frequent  than  the  blind 


340 


DISEASES  OF  THE  RECTUM  AND  ANUS 


internal  variety.  In  rare  instances  a  blind  external  fistula  may 
be  the  remains  of  a  complete  fistula  the  rectal  opening  of  which 
has  closed  spontaneously. 

Complete  Internal  Fistula  (Fig.  64,  B)  is  seldom  met  with. 
It  consists  of  a  sinus  with  two  openings,  both  into  the  rectum, 
and  is  very  difficult  to  diagnosticate,  but  easily  cured  when 
found. 

Complete  External  Fistula  (Fig.  65,  A)  is  also  quite  rare. 
It  consists  of  a  sinus  with  two  openings,  both  external  to  the 
rectum, — one  situated  at  the  margin  of  the  anus  and  the  other 
some  distance  away  upon  the  buttock. 

Recto-vaginal  Fistula  communicates  with  both  vagina  and 
rectum;  the  sinus  may  be  direct  or  tortuous  (Figs.  65,  B;  and 
66).     It  is  not  uncommon,  and,  when  the  opening  between 


Fig.   68. — Complex  Horseshoe  Fistula  with  Multiple  Openings  In 
and  Outside  the  Rectum. 


these  two  organs  is  large,  fecal  matter  may  escape  into  the 
vagina.  This  condition  is  sometimes  the  result  of  injury  to  the 
recto-vaginal  septum  during  parturition. 

Complex  Fistula  consists  of  multiple  sinuses  and  numerous 
openings  through  the  skin,  mucous  membrane,  or  both.  In 
these  cases  the  sinuses  extend  for  a  considerable  distance  be- 
neath the  mucous  membrane,  partially  or  completely  around 
the  bowel,  or  to  distant  organs  (Figs.  66  and  68).  It  occurs 
most  frequently  in  syphilitic  or  tuberculous  subjects. 

Horseshoe  Fistula  owes  its  name  to  the  fact  that  the  fistu- 
lous sinus  courses  around  the  rectum  from  one  side  to  the 
other,  and  is  shaped  somewhat  hke  a  horseshoe  (Fig.  67). 
There  are  one  or  more  openings  upon  the  buttocks  on  either 
side  of  the  anus,  communicating  with  each  other  and  with  the 


PLATE   XV.— CASE    OF   RECTOVESICAL    FISTULA    IN    NEGRO, 

SHOWING   RESULT   OF   EXTRAVASATION    OF    URINE 

INTO    BUTTOCK,    SCROTUM,    AND   PENIS. 


ANO-RECTAL  FISTULA 


241 


rectum,  usually  by  an  opening  into  the  posterior  wall  of  the 
bowel;  in  some  cases  there  may  be  two  or  even  more  open- 
ings into  the  rectum.  In  a  bad  case  of  horseshoe  fistula  there 
may  be  multiple  sinuses  and  openings  (Figs.  66  and  68). 
The  author  recently  operated  on  a  woman  in  whom  there  were 
forty-five  external  openings  and  thirty-two  sinuses.  The  but- 
tocks looked  very  much  as  if  a  load  of  buckshot  had  been 
emptied  into  them.  One  rarely  meets  with  two  cases  of  horse- 
shoe fistula  in  which  the  sinuses  take  the  same  direction. 

Eecto-vesical  Fistula  is  one  in  which  there  is  a  communica- 
tion between  the  rectum  and  the  bladder  (Fig.  69,  A;  and  Plate 
XV),   as  a  result  of  solution   of  the   partition  between   both 


Fig.  69. — A,  Recto-vesical  Fistula;  B,  Recto-urethral  Fistula. 


organs.  Flatus  and  feces  may  pass  through  the  urethra,  and 
the  urine  may  flow  into  the  rectum.  The  diagnostic  point  is 
the  passage  of  urine  and  feces  through  unnatural  channels. 
Recto-vesical  fistula  is  usually  caused  by  rupture  of  the  blad- 
der, urinary  calculi,  extensive  ulceration,  or  penetrating 
wounds.  The  author  has  treated  two  cases  due  to  rupture  of 
the  bladder  and  one  caused  by  a  very  large  urinary  calculus 
which  ulcerated  through  into  the  rectum  (see  chapter  on 
enteroliths). 

TTrinary,  or  Recto-urethral,  Fistula  is  rare,  indeed.     In  such 
cases  the  rectum  communicates  with  the  urethra  at  some  point 


242  DISEASES  OF  THE  RECTUM  AND  ANUS 

(Fig.  69,  B).  Cripps  has  reported  a  very  unusual  and  interest- 
ing case  which  healed  spontaneously.  This  condition  may  be 
due  to  traumatism;  disease  of  the  rectum,  prostate,  urethra, 
or  bladder;  or  to  operations.  The  author  once  treated  a  boy 
for  recto-urethral  fistula  following  rupture  of  the  urethra  and 
extravasation  of  urine,  caused  by  a  fall. 

Recto-labial  Fistula  (Fig.  66)  is  very  rare.  It  is  the  result 
of  abscess-formation  in  the  labia  or  perianal  tissue,  and  extends 
from  the  rectum  to  the  labia. 

For  literature  see  the  end  of  Chapter  XIX  (page  284). 


CHAPTER  XVII 

SYMPTOMS,  DIAGNOSIS,  AND  PROGNOSIS  OF  ANO- 
RECTAL FISTULA 

SYMPTOMS 

Patients  suffering  from  a  typic  fistula  usually  give  a 
history  of  a  chill  followed  by  throbbing  pain,  tenderness,  heat, 
and  swelling  in  the  ano-rectal  region,  and  also  the  ordinary 
symptoms  of  abscess,  which  disappeared  with  escape  of  the 
pus.  When  a  fistula  is  established,  the  following  symptoms  are 
present : — 

1.  Discharge  of  pus.  5.  Induration. 

2.  Pain  and  tenderness.  6.   Hypertrophy      of      the 

3.  Excoriation  of  the  mu-  sphincter-muscle. 

cous    membrane    and         7.  Pruritus, 
skin.  8.  Anxiety. 

4.  Passage    of    flatus    and        9.   Loss  of  weight. 

feces  through  the   si-      10.  Hemorrhage. 

nus.  11.   Fecal  incontinence. 

In  all  cases  of  fistula  there  is  a  more  or  less  free  discharge 
of  pus,  a  close  study  of  which  is  productive  of  much  informa- 
tion. The  secretion  from  a  blind  or  complete  internal  fistula 
is  discharged  into  the  rectum,  that  from  a  blind  or  complete 
external  variety  escapes  through  openings  in  the  skin,  and 
that  from  an  ordinary  complete  form  may  find  an  exit  in  either 
direction.  In  a  recent  fistula  the  discharge  is  constant,  abun- 
dant, thick,  and  yellow ;  while  that  from  one  of  long  standing 
is  slight,  thin,  watery,  and  whitish.  The  amount  of  pus  de- 
pends upon  the  length  and  size  of  the  sinus  and  the  number 
of  diverticula.  A  sudden  increase  in  the  quantity  indicates  that 
a  new  sinus  has  been  formed.  Sometimes  the  fistulous  open- 
ing becomes  closed  and  the  discharge  ceases  for  a  time,  leading 
the  patient  to  believe  that  he  is  well.  In  time,  however,  there 
occur  sudden  rise  in  temperature  and  acute  pain  and  swelling, 
which  are  soon  followed  by  a  discharge  of  pus  through  the  old 
opening  or  a  new  one  at  a  point  some  distance  from  it.     The 

(243) 


244:  DISEASES  OF  THE  RECTUM  AND  ANUS 

discharge  from  a  tubercular  Ustiila  is  thinner  and  less  in  amount 
than  that  from  an  ordinary  fistula  of  the  same  extent,  and  has 
the  characteristics  of  tubercular  pus. 

Pain  and  Tenderness  vary,  according  to  the  number  of 
sinuses,  the  size  of  their  openings,  and  their  relation  to  the 
anal  outlet.  As  a  rule,  there  is  little  pain  in  fistula  until  the 
openings  close  partially  or  completely,  when  it  increases  and 
becomes  more  acute.  Pain  is  greater  when  the  opening  is 
near  the  margin  of  the  anus,  owing  to  the  constant  irritation 
of  the  sphincter-muscle  and  acts  of  defecation.  Again,  suffer- 
ing is  increased  when  the  internal  opening  is  large  enough  to 
admit  fecal  matter. 

Excoriation  of  the  skin  and  mucous  membrane  of  the  ano- 
rectal region  is  always  present  in  greater  or  less  degree.  This 
causes  much  annoyance  when  walking,  riding,  or  sitting,  and 
is  aggravated  by  perspiration.  The  excoriations  may  become 
so  extensive  and  the  suffering  so  intense  that  the  patient  is 
rendered  unfit  for  business  or  social  duties. 

The  Passage  of  Flatus  and  Feces  into  the  sinus  may  occur  in 
internal  and  complete  fistula  when  the  rectal  opening  is  sufff- 
ciently  large,  but  this  does  not  take  place  as  frequently  as  is 
generally  supposed. 

Induration  exists  to  a  greater  or  less  degree  around  all 
fistulas,  and  it  is  more  marked  in  cases  of  long  standing.  It 
is  of  great  assistance  to  the  surgeon  in  determining  the  num- 
ber, direction,  and  length  of  fistulous  sinuses. 

Hypertrophy  of  the  Sphincter-muscle  sometimes  takes  place 
from  irritation,  especiall}^  in  cases  where  the  opening  of  the 
sinus  is  near  the  anus. 

Pruritus  of  the  Ano-gluteal  Region  is  nearly  always  a  persist- 
ent and  annoying  complication  of  fistula.  It  is  caused  by  the 
excoriations,  the  retention  and  decomposition  of  the  discharge 
within  the  radiating  folds  of  skin  about  the  anus,  or  the  escape 
of  a  diminutive  fecolith  into  the  sinus. 

The  Anxiety  evinced  by  this  class  of  patients  is  always 
noticeable,  and  in  some  cases  most  distressing,  totally  unfitting 
them  for  business  or  social  duties.  It  is  largely  due  to  the  fact 
that  these  sufferers  believe  that  fistula  is  incurable,  that  a  dan- 
gerous operation  followed  by  a  prolonged  convalescence  is 
necessary  for  its  relief,  or  that  the  discharge,  if  stopped,  will 
cause  a  development  of  disease  of  the  lungs  or  skin.    For  these 


ANORECTAL  FISTULA  245 

reasons  they  experiment  with  all  sorts  of  "cures"  and  suffer 
much  pain  and  annoyance  before  consenting  to  the  radical 
operation. 

Loss  of  Weight  is  sometimes,  but  not  always,  a  symptom  of 
fistula,  and  is  seen  most  frequently  in  tubercular  subjects. 

Fecal  Incontinence  is  seldom  a  symptom  of  fistula.  It  occurs 
only  in  cases  where  burrowing  and  destruction  of  tissue  have 
been  extensive,  or  where  an  operation  has  been  unsuccessful. 

In  addition  to  the  more  common  symptoms  enumerated 
above  there  are  other  manifestations  which  may  accompany 
fistula.  There  may  be  discoloration  of  the  parts,  foul  odor, 
or,  when  the  rectum  communicates  with  neighboring  organs, 
escape  of  gases  and  feces  through  the  urethra  or  vagina  and 
of  urine  through  the  rectum.  In  rccto-vesical  fistula  there  is 
usually  a  cystitis  from  irritation.  It  is  also  important  to  re- 
member that  fistula  may  be  secondary  to  disease  of  the  ad- 
jacent organs, — vertebra,  sacrum,  coccyx,  pelvic  bones,  or 
•  hip-joint;  furthermore,  that  it  is  often  a  symptom  of  stricture, 
carcinoma,  hemorrhoids,  ulceration,  and  fissure  of  the  rectum 
and  anus. 

DIAGNOSIS 

When  a  fistula  is  suspected,  before  trying  to  determine  its 
exact  nature  it  is  well  to  bear  in  mind  the  following  points: — 

1.  A  fistulous  sinus  may  open  into  any  part  of  the  rectum, 
or  upon  the  skin  at  any  point  in  the  ano-gluteal  region,  or  into 
neighboring  organs. 

2.  The  openings  may  vary  in  size  and  shape  and  be  single 
or  multiple.  Multiple  openings  indicate  chronicity,  a  debili- 
tated constitution,  or  an  original  small  opening  and  improper 
drainage. 

3.  The  sinus  may  be  long,  or  short  and  single ;  or  it  may 
be  straight,  or  tortuous  with  many  branches. 

4.  Two  or  more  entirely  independent  fistulous  sinuses 
may  exist  in  the  same  case. 

5.  In  ordinary  complete  fistula  the  openings  are  in  a  direct 
line,  and  the  internal  opening  will  usually  be  found  posteriorly 
at  the  junction  of  the  internal  and  external  sphincter-muscles. 

6.  In  fistulas  of  tubercular  and  non-tubercular  origin  there 
is  a  marked  difference  in  both  the  appearance  of  the  patient 
and  the  characteristics  of  the  sinuses. 


246  DISEASES  OF  THE  RECTUM  AND  ANUS 

Making  a  correct  diagnosis  requires  plenty  of  time,  a 
strong  light,  a  suitable  table,  and  several  probes  of  different 
sizes.  A  posture  should  be  selected  which  gives  the  best  view 
of  the  affected  side.  Ordinarily  the  Sims  and  lithotomy  posi- 
tions are  the  most  desirable  postures.  Where  a  sinus  opens 
into  the  upper  rectum,  however,  the  patient  must  be  placed 
in  the  genu-pectoral  position,  otherwise  inflation  and  a  good 
view  of  this  part  of  the  bowel  is  impossible. 

Under  ordinary  circumstances  complete  fistula  is  not  diffi- 
cult to  diagnosticate.  Some  of  the  other  varieties,  however, 
especially  the  blind  internal  and  horseshoe,  require  much  pa- 
tience, not  only  to  locate  the  openings,  but  to  determine  the 
direction  and  extent  of  the  sinuses. 

When  searching  for  fistulas  the  buttocks  should  be  well 
separated  and  the  ano-gluteal  region  closely  inspected;  over- 
lapping folds  of  skin  should  be  pulled  apart,  and,  finally,  the 
lips  of  the  anus  everted;  in  this  way  external  openings  will  be 
seen.  When  they  are  found  their  number  and  appearance 
should  be  noted,  as  reliable  information  can  be  had  from  this 
source.  When  the  opening  is  small,  round,  and  situated  in  the 
midst  of  a  little  mass  of  granulations  projecting  from  the  center 
of  a  slight  elevation,  a  simple  or  ordinary  fistula  is  to  be  dealt 
with.  On  the  other  hand,  when  the  opening  is  large,  irregidar 
in  shape,  and  its  edges  have  a  bluish  tint  and  droop  inivard,  the 
fistula  is  most  Hkely  to  be  of  tubercular  origin.  The  ano-peri- 
neal  region  should  next  be  palpated  carefully.  Superficial, 
deep,  and  branched  sinuses  can  be  detected  by  their  indurated 
(tube-like)  feel,  especially  when  they  have  existed  for  a  con- 
siderable time. 

The  direction  of  the  sinus  is  determined  by  palpation  and 
probing.  In  some  instances  the  probe  must  be  bent  at  various 
angles  before  it  can  be  made  to  follow  the  tract.  Care  and  gen- 
tleness should  be  exercised  when  probing  a  fistula,  otherwise 
the  probe  may  be  forced  through  the  wall  of  the  sinus  and  into 
the  loose  tissue,  leading  the  examiner  to  believe  that  the  fistula 
is  very  extensive,  when,  in  reality,  it  is  short  and  simple.  More- 
over, this  accident  may  lead  to  the  formation  of  an  abscess 
and  a  second  fistula.  In  the  majority  of  fistulas  the  internal 
opening  is  located  posteriorly,  about  half  an  inch  (1.27  centime- 
ters) above  the  anus  and  between  the  external  and  internal 
sphincters,  but  it  may  be  located  in  any  part  of  the  rectum. 


ANO-RECTAL  FISTyLA  247 

Sometimes  they  are  concealed  in  the  folds  of  the  mucosa,  rec- 
tal glands,  or  in  the  semilunar  valves.  Usually  they  can  be  felt 
easily  by  the  finger  dipping  into  them  when  large  and  by  the 
indurated  or  ulcerated  spots  when  small.  It  is  difficult  to  find 
them  through  the  speculum  unless  they  are  of  goodly  size.  A 
close  examination  of  the  mucosa  gives  some  idea  of  the  situa- 
tion of  the  opening,  around  which  the  mucous  membrane  is 
chafed,  highly  inflamed,  and  very  sensitive. 

In  complete  fistula,  where  the  internal  opening  cannot  be 
located  in  any  other  way,  milk,  dilute  iodine,  methylene-blue, 
or  other  colored  solution  should  be  injected  into  the  sinus,  and 
it  will  be  seen  forcing  its  way  into  the  bowel.  The  author  has 
in  several  cases  succeeded  in  locating  the  rectal  opening  by 
injecting  carbonic-acid  gas. 

Goodsall  maintains  that  the  internal  opening  of  a  fistula 
will  generally  be  found : — 

1.  "In  the  middle  line,  posteriorly,  either  immediately 
above  the  inner  margin  of  the  external  sphincter  or  in  Hilton's 
white  line :  i.e.,  at  a  spot  corresponding  to  the  interval  between 
the  internal  and  external  sphincters." 

2.  "On  the  right  anterior  side  of  the  rectum,  between  the 
internal  and  external  sphincters." 

3.  "On  the  left  anterior  side  of  the  rectum  between  the 
internal  and  external  sphincters." 

In  any  form  of  fistula  where  other  openings  are  suspected 
which  cannot  be  seen  either  in  the  rectum  or  upon  the  surface, 
their  location  can  be  determined  by  injecting  the  sinus  with 
peroxide  of  hydrogen,  which,  when  given  a  little  time,  can  be 
seen  bubbling  out  at  such  points. 

Complete  and  blind  or  complete  external  fistulse  are  easily 
recognized,  because  the  external  openings  can  be  seen  and  the 
tracts  followed  with  little  dii^culty. 

Horseshoe  fistula  can  be  diagnosticated  from  the  presence 
of  openings  on  both  sides  of  the  anus.  In  some  cases,  how- 
ever, it  is  difficult  to  determine  the  number  and  location  of 
internal  openings  and  the  number  and  direction  of  the  sinuses 
and  their  diverticula. 

In  the  absence  of  other  rectal  disease  discharge  from  the 
bowel,  painful  defecation,  inflamed  mucosa,  and  a  doughy 
swelling  in  the  rectum  point  to  the  existence  of  a  blind  or  com- 
plete internal  fistula. 


248  DISEASES  OF  THE  RECTUM  AND  ANUS 

A  diagnosis  of  recto-vesical  or  recto-urethral  fistula,  where 
the  openings  cannot  be  seen  and  located,  can  be  made  when 
urine  is  discharged  with  the  feces,  or  when  feces  and  flatus 
are  voided  with  the  urine.  In  recto-vesical  fistula  (usually 
congenital)  the  opening  is  often  large ;  the  amount  of  feces 
discharged  into  the  bladder  is  considerable,  and  continually 
excites  an  annoying  cystitis,  or  it  may  obstruct  the  urethra. 
In  recto-urethral  fistula  there  is  inflammation  of  the  urethra 
and  sometimes  cystitis  from  extension  of  the  former  inflam- 
mation to  the  bladder.  In  order  to  differentiate  between  recto- 
vesical and  recto-urethral  fistulas,  the  bladder  should  be  filled 
with  a  colored  solution;  if  the  fistula  is  of  the  former  variety 
the  fluid  immediately  flows  into  the  rectum,  but  if  of  the  latter 
form  it  is  discharged  only  during  micturition. 

The  escape  of  feces  and  gas  through  an  opening  in  the 
vagina  or  labia  is  unmistakable  evidence  of  recto-vaginal  or 
recto-labial  fistula.  In  many  cases,  however,  these  openings  are 
so  small  that  the  passage  of  feces  or  gas  is  impossible.  It  then 
becomes  necessary  to  closely  examine  the  recto-vaginal  sep- 
tum or  labia  to  find  the  outlet  of  the  sinus,  which  will  usually 
be  found  in  the  center  of  a  small,  inflamed  spot  caused  by  the 
discharge. 

It  is  easy  to  differentiate  tubercular  from  simple  fistula. 
The  former  almost  always  occurs  in  emaciated  persons  who 
may  or  may  not  have  had  a  hemorrhage  from  the  lungs ;  their 
openings  are  large,  irregular  in  shape,  and  the  edges  are  of  a 
bluish  tint  and  droop  inward  as  a  result  of  the  undermining 
of  the  skin.  For  a  further  discussion  of  the  differential  diag- 
nosis of  tubercular  and  non-tubercular  fistulas,  the  reader  is 
referred  to  the  chapter  on  "The  Relation  of  Phthisis  to  Fistula 
in  Ano." 

PROGNOSIS 

When  properly  treated  the  prognosis  in  cases  of  ordinary 
fistula  in  ano  is  always  good,  especially  in  so  far  as  life  is  con- 
cerned. When  ignored  or  badly  treated,  many  new  sinuses 
may  form,  causing  prolonged  suffering  and  sometimes  death 
from  exhaustion,  or  extension  to  neighboring  organs  or  the 
peritoneal  cavity.  In  cases  of  tuhercnlar  fistula  the  prognosis 
is  always  grave,  on  account  of  the  tendency  of  the  fistula  to 
extend  rather  than  to  heal.     In  the  author's  experience,  these 


ANORECTAL  FISTULA  249 

cases,  when  radically  treated  and  sent  to  a  proper  climate,  re- 
cover more  frequently  than  is  generally  supposed.  Secondary 
abscesses  or  death  from  sepsis  are  of  rare  occurrence,  except 
in  those  instances  in  which  the  surgeon  closes  his  incision  and 
fails  to  provide  for  proper  drainage  and  protection  against 
infection. 

The  accident  which  surgeons  fear  most  in  operations  for 
relief  of  fistula  in  ano  is  fecal  incontinence;  this  seldom  occurs, 
however,  unless  the  sphincter-muscle  has  been  cut  in  sigzag 
fashion  (Fig.  76)  or  the  after-treatment  of  the  wound  has  been 
neglected. 

The  time  required  for  the  cure  of  fistula  depends  upon  the 
length  and  depth  of  the  sinus,  the  number  of  diverticula,  and 
the  vitaHty  of  the  patient.  The  majority  of  these  patients  re- 
cover in  two  or  three  weeks,  but  others  may  require  many 
weeks  or  months  before  a  permanent  cure  is  accomplished. 

For  Literature  see  the  end  of  Chapter  XIX  (page  284). 


CHAPTER  XVllI 

TREATMENT  OF  ANO=RECTAL  FISTULA 

Now  and  then  a  case  is  reported  where  a  fistula  has  healed 
spontaneously;  but  it  is  needless  to  say  that  this  is  of  very 
rare  occurrence.  The  treatment  of  fistula  is  non-operative  and 
surgical. 

NON=OPERATIVE  TREATMENT 

Palliative  treatment  seldom  effects  a  cure,  but  does  di- 
minish the  suiTering  of  the  patient  and  tends  to  prevent  the 
extension  of  the  disease  and  the  formation  of  new  sinuses. 
Palliative  measures  consist  principally  in  (a)  improving  the 
patient's  general  condition  by  the  administration  of  iron,  cod- 
liver-oil,  creasote,  the  hypophosphites,  strychnine,  quinine, 
wines,  malt  preparations,  and  other  tonics  and  tissue-builders; 
(h)  regulating  the  stools;  (c)  keeping  the  sinus  clean  by  irri- 
gating with  peroxide  of  hydrogen,  bichloride  of  mercury, 
carbolic  acid,  and  other  antiseptic  solutions  of  suitable  strength; 

(d)  the  application  to  the  fistulous  tract  of  the  balsam  of  Peru, 
silver  nitrate,  ichthyol,  silver  lactate,  nitric  or  carbolic  acid, 
zinc  chloride,  and  similar  stimulating  and  escharotic  remedies; 

(e)  rest  and  avoidance  of  horseback-riding,  cycling,  and  other 
violent  exercise;  (f)  protecting  the  ano-gluteal  region  from 
the  discharge  by  placing  a  piece  of  cotton  or  gauze  between 
the  buttocks ;  (g)  bathing  the  excoriated  parts  frequently  with 
mild  boric-acid  solution,  drying  well,  dusting  with  talcum  pow- 
der, zinc  stearate,  or  prepared  chalk,  and  then  covering  with 
cotton. 

SURGICAL  TREATMENT 

It  has  been  the  custom  of  the  author  to  advise  immediate 
operation  in  all  fistula  cases,  irrespective  of  the  extent  and  char- 
acter of  the  sinus,  provided  the  general  health  of  the  patient 
permits.  He  does  not  consider  it  wise  to  operate  upon  persons 
in  the  last  stages  of  phthisis,  nephritis,  diabetes,  or  organic 
heart  disease ;  neither  does  he  consider  it  good  judgment  to 
advise  against  operation  simply  because  there  is  moderate 
lung  involvement  or  where  there  is  an  acute  inflammation  in 
and  around  the  sinus. 
(250) 


TEEATMENT  OF  ANORECTAL  FISTULA  251 

There  is  no  class  of  surgical  operations  which  requires 
more  skill,  ingenuity,  and  patience,  both  during  the  operation 
and  after-treatment,  than  those  for  the  relief  of  fistula  in  ano. 

If  the  patient  is  run  down,  his  general  condition  should 
be  improved  as  much  as  possible  prior  to  the  operation,  by 
the  administration  of  the  remedies  suggested  in  the  palliative 
treatment. 

The  following  are  the  principal  operations  which  have 
been  devised  for  the  relief  of  fistula : — 

1.  Dilatation.  5.   By  fistulatome. 

2.  Injection    of    astringent       6.   Excision. 

fluids.  7.  Division     by      (a)     the 

3.  Ligation.  knife ;      (b)     Paquelin 

4.  Electrolysis     and     ecra-  cautery-point. 

seur. 

The  patient  should  be  prepared  by  a  cathartic, — salts, 
licorice-powder,  Carabana  water,  etc., — on  the  morning  of  the 
day  before  the  operation ;  this  should  be  followed  by  an  enema 
of  soap-suds  (about  2  quarts — 1800  cubic  centimeters)  six  hours 
previous  to,  and  a  smaller  injection,  composed  of  sterile  water 
and  2  ounces  (60  cubic  centimeters)  of  glycerin  (about  V2  pii'^t 
■ — 237  cubic  centimeters),  two  hours  previous  to  the  operation. 
In  spite  of  all  precautions  it  will  be  found  impossible  in  some 
cases  to  prevent  the  field  of  operation  from  becoming  deluged 
with  feces.  In  such  cases  the  operation  must  be  discontinued 
until  the  parts  are  again  thoroughly  cleansed  by  means  of 
copious  irrigation  with  sterile  water  or  antiseptic  solutions. 
The  outer  parts  should  be  prepared  in  the  same  manner  as  for 
operations  elsewhere,  but,  unless  the  operator  intends  to  ex- 
cise the  fistula  and  obtain  primary  union,  the  patient  can  be 
saved  much  annoyance  by  not  shaving  the  parts. 

The  following  instruments  are  necessary  in  fistula  opera- 
tions : — 

Operating  speculum. 

Two  strong  bistouries,  one  straight  and  one  curved. 

Probes  of  various  sizes. 

Two  straight  grooved  directors,  one  steel  and  one  brass. 

One  angular  grooved  director. 

One  small,  sharp,  steel  curette. 


252  DISEASES  OF  THE  RECTUM  AND  ANUS 

Artery-forceps. 

Plain  and  chromicized  catgut. 

Hagedorn  needles  (curved)  of  various  sizes. 

Two  retractors. 

One  gorget. 

Straight  and  curved  scissors. 

Too  much  care  cannot  be  exercised  in  the  selection  of 
cutting  instruments  for  fistula  operations.  They  must  be 
strong  and  of  the  best  metal,  else  they  are  liable  to  snap  in 
two  when  dividing  a  deep  sinus  composed  of  scar-tissue.  The 
autnor  had  the  misfortune  in  one  case  to  break  the  knife ;  the 
operation  was  considerably  delayed  thereby  before  the  broken 
blade  could  be  located  and  removed. 

The  position  selected  in  operations  for  fistula  in  ano 
depends  upon  the  number  and  location  of  the  sinuses.  That 
posture  should  be  chosen  which  gives  plenty  of  room  to  the 
hands  and  a  good  view.  The  lithotomy  position  will  be  found 
desirable  in  the  majority  of  cases,  though  the  Sims  is  fre- 
quently resorted  to ;  in  exceptional  cases  it  becomes  necessary 
to  place  the  patient  flat  upon  the  abdomen,  especially  when 
the  sinus  is  situated  over  the  sacrum  or  coccyx. 

Of  the  operations  about  to  be  described,  that  of  complete 
division  of  the  sinus  should  be  selected,  unless  the  patient  has 
phthisis,  desires  the  fistula  excised,  or  refuses  the  knife  undei 
any  circumstances. 

Dilatation. — This  operation  consists  in  keeping  the  mouth 
and  all  or  part  of  the  sinus  dilated,  so  that  the  pus  may  have 
a  free  exit,  and  in  stimulating  the  granulations  by  lacerating 
the  sinus  along  its  entire  length  with  some  rough  instrument 
(wire  curette)  or  by  the  direct  application  of  escharotic  or 
astringent  remedies,  such  as  zinc,  silver  nitrate,  alum,  and 
nitric  or  carbolic  acid.  Allingham  prefers  the  latter,  and  in 
addition  inserts  a  rubber  drainage-tube  into  the  sinus  and 
gradually  withdraws  it  as  healing  takes  place.  The  dilatation 
may  be  made  with  instruments,  graduated  probes,  sponge-tents, 
or  anything  which  enlarges  the  outlet  of  the  sinus  to  the  de- 
sired size.  This  procedure  scarcely  deserves  to  be  classified 
as  an  operation ;  at  the  same  time,  it  does  not  properly  belong 
under  palliative  treatment. 

Injection  of  Astringent  Fluids.  —  The  ordinary  astringents 
and  escharotics — zinc,  iron,  silver,  carbolic  acid,  or  ergot,  in 


TREATMENT  OF  ANORECTAL  FISTULA  253 

varying-  strengths — will  do  as  well  as  any  others,  possibly  with 
the  exception  of  ergotine,  which  gives  the  best  results.  They 
must  be  injected  both  into  and  around  the  sinus.  If,  by  any 
means,  fecal  matter  and  flatus  can  be  kept  out  of  the  sinus 
during  the  treatment,  a  very  important  point  has  been  gained. 
To  do  this  the  author  resorts  to  the  following  plan :  After  the 
sinus  has  been  cleansed  with  water,  peroxide  of  hydrogen,  or 
some  other  antiseptic  solution,  a  probe  threaded  with  a  silk 
thread,  to  the  end  of  which  is  attached  a  small  wad  of  cotton, 
is  passed  through  the  external  opening  and  into  the  rectum, 
and  then  caught  and  drawn  downward  through  the  anus ;  the 
cotton  is  thereby  carried  upward  along  the  sinus  until  it  can 
be  felt  just  beneath  the  mucous  membrane  near  the  internal 
opening;  the  probe  is  then  detached  and  the  thread  left  hang- 
ing outside  the  anus.  In  this  way  all  fecal  communication  is 
cut  ofT.  Injection  is  then  made  into  and  around  the  sinus,  and 
the  needle  withdrawn  slowly  as  the  fluid  is  forced  out.  An 
ordinary  hypodermic  syringe  can  be  used,  but  an  extension 
piece  or  extra  needle,  with  a  blunt  end,  about  three  inches 
(7.6  centimeters)  in  length,  simplifies  the  operation.  This  pro- 
cedure requires  to  be  repeated  several  times.  When  healing 
takes  place  it  is  from  within  outward,  and  when  it  reaches  the 
surface  of  the  body  the  cotton  can  be  removed  from  the  rec- 
tum by  drawing  out  the  thread;  a  final  injection  should  be 
made  into  the  bowel  at  the  seat  of  the  internal  opening,  and 
this  completes  the  treatment.  The  author  has  cured  a  few 
cases  in  this  way,  and  the  patients  were  very  grateful ;  in 
many  other  cases,  however,  this  treatment  proved  a  total  fail- 
ure. This  method  of  treating  fistula  causes  more  pain  and 
requires  a  longer  time  to  effect  a  cure  than  does  the  more 
reliable  operation  of  division.  Heahng  is  more  likely  to  follow 
the  injections  when  the  tract  has  been  previously  curetted  with 
a  wire  curette. 

Ligation.  —  To  Professor  Dittel  and  Allingham,  Sr.,  be- 
longs the  credit  of  popularizing  this  method  of  operating  upon 
fistula  in  ano.  Neither  of  them,  however,  originated  it,  for 
an  accurate  description  of  it  has  been  given  by  Celsus.  The 
operation  consists  m  passing  a  ligature  through  the  sinus 
and  out  at  the  anus  (Fig.  70) ;  after  it  has  been  tied  tightly 
it  constricts  all  intervening  tissues  (Figs.  71  and  72)  and 
cuts  its  way  out  by  pressure-necrosis.     The  ligature  can  be  in- 


354 


DISEASES  OF  THE  RECTUM  AND  ANUS 


troduced  threaded  on  an  ordinary  probe  which  has  an  eye, 
or  by  the  aid  of  Mr.  AlHngham's  ingenious  instrument  (Fig. 
73),  by  means  of  which  it  can  be  drawn  from  within  the  rec- 
tum to  the  outside.  The  hgature  used  may  be  of  silk  or 
rubber,  the  latter  being  preferable  because  it  makes  uniform 
pressure.  A  piece  of  solid  India  rubber  from  one-twelfth  to 
one-eighth  of  an  inch  (2.2  to  3.2  millimeters)  in  thickness,  is 
the  most  desirable.  The  ends  can  be  secured  by  slipping  over 
the  knot  a  piece  of  lead  with  a  slit  in  it,  which  is  then  secured 
by  the  aid  of  strong  forceps.  The  following  are  some  of  the 
advantages  claimed  for  the  ligature  operation : — 


Fig.  70. 


Fig.  71. 


Fig.  72. 


Showing  Ligature  Operation  for  Fistula  in  Ano.     A,  First  Step; 
B,  Second  Step;  C,  Third  Step. 


1.  It  does  away  with  the  knife. 

2.  Can  be  performed  without  an  anesthetic. 

3.  It  is  comparatively  painless. 

4.  It  permits  the  patient  to  walk  about  in  the  fresh  air  and 
sunshine. 

5.  There  is  no  bleeding. 

Some  of  the  objections  to  this  operation  may  be  enu- 
merated as  follows : — 

1.  It  requires  a  longer  time  to  effect  a  cure  than  does 
incision. 


TREATMENT  OF  ANO-RECTAL  FISTULA 


255 


2.  Only  the  main  sinus  is  divided;  hence  the  operation 
will  be  a  failure  when  there  are  diverticulae. 

3.  The  ligatures  have  been  known  to  cut  only  part  of  the 
way  out,  thus  delaying  convalescence  and  requiring  the  knife 
to  divide  the  remaining  tissues. 

4.  It  is  not  suitable  for  operations  on  fistulas  in  general. 
In  the  author's  opinion,  the  ligature  operation  should  be 

confined  to  persons  who  refuse  to  be  operated  upon  by  the 
knife  and  those  who  are  anemic  or  phthisic.     This  operation 


Fig.  73. — AUingham's  Elastic  Ligature  Carrier. 

is  especially  adapted  for  the  treatment  of  fistula  in  tubercular 
subjects,  for  the  reason  that  they  can  take  their  usual  amount 
of  out-door  exercise  with  comparatively  little  annoyance,  lose 
little  blood,  and  also  because  they  avoid  taking  a  general  anes- 
thetic. 

Electrolysis  and  Ecraseur.  —  Periodically  some  one  writes 
a  paper  advocating  the  treatment  of  fistula  by  electrolysis, 
severing  the  sinus  with  the  galvanocmitery-zvire  or  with  the 
ecraseur.     These  procedures  are  mentioned  here  only  to  be 


Fig.  74. — Fistulatome. 


condemned  as  unreliable,  painful,  and  as  invariably  resulting 
in  prolongation  of  the  patient's  suffering. 

By  Fistulatome.  —  That  distinguished  Southern  surgeon, 
Dr.  Mathews,  of  Louisville,  Ky.,  has  devised  a  very  ingeni- 
ous instrument  for  the  cure  of  fistula,  the  "fistulatome"  (Fig. 
74),  which  he  recommends  in  selected  cases.  As  the  author 
has  never  used  this  instrument,  he  can  neither  commend  nor 
condemn  it  from  a  practical  stand-point.  He  believes,  how- 
ever, that  its  sphere  of  usefulness  is  limited  to  cases  where 
extensive  cutting  is  contra-indicated  and  where  patients  can- 


256  DISEASES  OF  THE  RECTUM  AND  ANUS 

not   be   persuaded   to   submit   to   a   better   and   more   radical 
operation. 

Excision. — A  few  years  ago  Dr.  Fredericl<:  Lange  reported 
a  number  of  cases  successfully  treated  by  excision,  and  highly 
recommended  this  operation.  For  some  reason  the  operation 
has  not  become  popular.  It  is  performed  as  follows :  The 
entire  sinus  is  laid  open  in  a  manner  similar  to  that  in  the 
operation  of  complete  division.  All  of  the  old  fistulous  tract 
is  then  carefully  dissected  out,  and  the  edges  of  the  wound 
perfectly  adjusted  with  catgut  sutures,  and  a  dry  dressing  ap- 
plied. If  the  operation  is  a  success  there  will  be  very  little 
need  for  after-dressings,  since  the  wound  heals  in  a  few  days 
by  primary  union.  In  case  it  should  not  be  successful,  the 
wound  can  be  treated  by  the  method  employed  after  the  or- 
dinary operation  of  division.  The  author  has  performed  this 
operation  a  number  of  times,  and  has  not  been  satisfied  with 
it  because :  (a)  it  is  more  difficult,  requires  a  longer  time  to 
perform,  and  does  not  give  as  good  results  as  simple  division; 
(b)  considerable  blood  is  lost;  (c)  primary  union  is  not  always 
obtained  because  of  infection;  (d)  the  operation  is  frequently 
followed  by  a  fresh  abscess  and  the  formation  of  a  new  sinus. 
This  operation  proved  successful  in  some  cases  where  there 
were  two  or  more  external  openings  with  sinuses  communi- 
cating with  each  other  and  with  the  rectum.  By  dissecting 
out  the  sinuses  between  the  external  openings  and  bringing 
the  edges  together  with  catgut  sutures,  after  the  main  tract 
had  been  divided  and  the  wound  left  open,  a  good  result  was 
obtained  in  several  instances.  The  sinuses  between  the  exter- 
nal openings  healed  by  first  intention,  while  the  main  tract, 
leading  into  the  rectum,  healed  by  granulation.  A  great  ad- 
vantage of  the  excision  operation  is  that,  when  successful,  only 
one  or  two  weeks  are  required  for  a  cure  even  in  extensive 
cases.  This  operation  is  not  universally  successful,  because  of 
tension  on  the  sutures,  activity  of  the  sphincter-muscles,  strain- 
ing during  defecation,  and  the  great  difficulty  experienced  in 
keeping  the  rectal  end  of  the  wound  from  becoming  infected. 
It  is  best  suited  to  fistula  cases  fa)  in  which  the  internal  open- 
ing is  at  or  near  the  anal  margin  and  fb)  in  tubercular  patients, 
in  whom  a  speedy  convalescence  is  especially  desirable. 

Division. — Of  the  various  operations  devised  for  the  cure 
of  fistula,  complete  division  of  the  sinus  is  the  simplest  and 


1 

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TREATMENT  OF  ANO-RECTAL  FISTULA  257 

most  reliable.  When  the  fistula  is  short  and  superficial,  general 
anesthesia  is  not  necessary,  because  the  skin  and  structures 
overlying  the  sinus  can  be  divided  with  little,  if  any,  pain  after 
freezing  them  with  liquid  air,  ether-spray,  ethyl  chloride,  or  after 
being  anesthetized  by  the  injection  of  sterile  water,  or  a  weak 
solution  of  eucaine  or  cocaine.  Eucaine  is  preferable,  because 
it  can  be  sterilised,  and,  in  the  author's  experience,  fewer  dan- 
gerous and  unpleasant  symptoms  have  followed  its  use. 

In  persons  who  object  to  general  anesthesia  or  confinement 
to  bed  and  also  in  those  afflicted  with  serious  disease  of  the  heart, 
kidneys,  or  lungs,  the  sinus  may  be  satisfactorily  divided  under 
local  anesthesia. 

When    a   general   anesthetic   is    necessary,    the    operator 


Fig.  75.— Right  Way  to  Cut  the  Sphinc-         Fig.  76.— Wrong  Way  to  Cut  the  Sphinc- 
ter in  Operations  for  Fistula  in  Ano.  ter  in  Operations  for  Fistula  in  Ano. 


should  have  at  least  two  assistants, — the  anesthetist  and  an- 
other to  hold  the  buttocks  well  apart ;  and,  if  a  third  handle  the 
instruments  and  sponges,  time  can  be  saved. 

The  steps  in  the  operation  for  division  of  a  complete 
fistula  are  as  follows  (Plate  XVI) :  After  the  sphincters  have 
been  divulsed  and  the  rectum  washed  out,  a  probe-pointed 
grooved  director  is  introduced  into  the  outer  opening  and 
passed  through  the  sinus  and  inner  opening  into  the  rectum. 
The  distal  end  of  the  director  is  then  brought  out  through  the 
anus  by  the  index  finger  of  the  left  hand  inserted  into  the 
rectum  for  that  purpose.  Then  with  a  strong  bistoury,  either 
straight  or  curved,  the  entire  bridge  of  tissue  resting  upon 
the  director  is  divided.     This  should  be  done  as  nearly  at  a 


258 


TREATMENT  OF  ANO-RECTAL  FISTULA 


right  angle  (Fig.  75)  to  the  sphincter  as  possible,  and  not  in 
an  oblique  direction  or  zigzag  fashion  (Fig.  76)  as  some  op- 
erators do,  for  incontinence  is  apt  to  follow  the  latter.  After 
the  bridge  of  tissue  has  been  divided,  the  opposite  wall  of  the 
tract  is  incised,  this  incision  being  known  as  Salmon's  back- 
cut.  The  entire  sinus  must  now  be  excised  or  curetted,  bleeding 
vessels  ligated,  and  undermined  or  irregular  pieces  of  skin  cut 
away.  The  wound  is  then  packed  tightly  with  sterile  or  antiseptic 
gauze,  over  which  a  piece  of  absorbent  cotton  is  placed;  these 
dressings  are  secured  in  position  by  a  strong,  well-adjusted 
T-bandage  or  the  author's  operating  harness. 

When    the    external    opening    is    not    of    sufficient    size    to 


Fig.  77.— Author's  Sets  of  Graduated  Probes  and  Grooved  Directors. 


admit  a  probe  or  director,  it  should  be  enlarged  by  a  short 
incision  made  transversely  to  the  main  sinus.  In  cases  where 
the  internal  opening  cannot  be  located  and  in  those  where  the 
sinus  extends  so  close  to  the  rectum  that  the  end  of  the  in- 
strument can  be  felt  from  within,  the  director  should  be  forced 
through  the  bowel-wall  and  the  operation  completed  as  de- 
scribed. 

Branch-sinuses  should  be  operated  upon  by  passing  the 
director  from  one  external  opening  to  the  other  and  dividing 
the  tissues  until  all  are  made  to  communicate  with  each  other 
and  the  main  sinus.  Or  the  main  sinus  may  be  divided  first, 
when,  by  careful  sponging,  the  diverticula  will  be  seen  opening 
into  it  at  points  marked  by  small  masses  of  dark  granulations, 


TREATMENT  OF  ANORECTAL  FISTULA 


259 


and  they  may  then  be  divided.  In  other  cases  where  the 
fistulous  tract  is  tortuous,  it  is  necessary  to  proceed  slowly 
and  divide  the  sinus  in  sections  by  inserting  the  director  as  far 
as  possible  and  severing  the  overlying  tissue;  the  further 
course  of  the  sinus  is  then  determined  by  probing,  and  the 
procedure  repeated  as  often  as  is  necessary.  When  the  fistula 
is  not  deep,  the  grooved  silver  director  is  preferable,  because 
it  is  more  pliable.  In  cases  of  extensive  fistula  it  is  well  to 
have  a  number  of  grooved  steel  directors,  of  different  lengths 


Fig.  78. — Gorget. 


and  sizes  (Fig.  77),  which  will  not  bend,  to  use  in  operations 
where  the  sinuses  are  long  and  indurated,  and  where  the  in- 
ternal opening  is  situated  so  high  up  in  the  rectum  that  the 
distal  end  of  the  director  cannot  be  brought  out  at  the  anus. 
In  such  cases  a  piece  of  soft  wood,  or  a  steel  gorget  (Fig. 
78),  one-half  inch  (1.27  millimeters)  wide  and  eight  inches  (2 
decimeters)  long,  is  introduced  into  the  rectum  after  the  direc- 
tor is  in  proper  position.  The  knife  is  then  made  to  follow 
the  director  along  the  fistulous  tract  until  its  point  enters  the 


Fig.  79. — Allingham's  Scissors  and  Grooved  Director. 


rectum  and  is  pressed  into  the  piece  of  wood.  Both  should 
then  be  withdrawn  together,  thus  severing  all  the  intervening 
tissues.  Allingham's  scissors  and  director  are  especially 
adapted  for  such  cases  (Figs.  79  and  80).  There  is  a  knob 
on  the  under-surface  of  the  lower  blade  of  the  scissors  which 
is  made  to  follow  in  the  oval  groove  in  the  director,  cutting 
the  tissues  from  without  inward.  Another  and  a  better  way 
when  the  sinus  reaches  high  up  in  the  bowel,  or  when  other 
sinuses  are  suspected,  is  to  dissect  slowly  from  below  upward, 
following  the  director  until  the  end  of  the  sinus  is  reached; 


260 


DISEASES  OF  THE  RECTUM  AND  ANUS 


then  any  diverticula  from  the  main  sinus  will  not  be   over- 
looked. 

The  sphincter-muscles .  should  not  be  severed  in  fistula 
operations  oftener  than  is  absolutely  necessary ;  they  may  be 
cut  one,  tzvo,  or  three  times,  however  (Fig.  93),  when  neces- 
sity demands,  and  incontinence  will  not  follow,  especially  if  the 
incisions  are  superficial.  It  is  the  high  incisions  which,  by 
dividing  both  the  external  and  internal  sphincters,  cause  fecal 
incontinence.  Goodsall  lays  special  stress  upon  the  danger  of 
incontinence  when  the  internal  sphincter  is  cut. 


Fig. 


-Proper  Method  of  Using  Allingham's  Scissors  and  Director. 


The  principle  features  of  the  operation  for  complete  fistula 
are  apphcable  to  the  other  forms,  but  the  technic  must  be  varied 
to  suit  the  case. 

Blind  External  Fistula  is  operated  upon  by  inserting  the 
grooved  director  into  the  sinus  as  far  as  possible ;  then  it  is 
forced  through  into  the  rectum,  and  the  operation  finished  as 
in  complete  fistula. 

Blind  Internal  Fistula  is  more  difificult  to  operate  upon  than 
is  the  one  just  described,  because  the  sinus  is  frequently  tort- 
uous and  may  take  any  direction,  thus  rendering  it  extremely 
difificult  to  insert  the  director  and  incise  it.    When  the  opening 


TREATMEMT  OF  ANO-RECTAL  FISTULA  261 

is  near  the  anus  and  the  sinus  passes  directly  or  obhquely  up- 
ward beneath  the  mucous  membrane,  the  director  should  be 
passed  to  the  upper  limit  of  the  tract,  pushed  through  the  mu- 
cosa, and  the  membrane  divided  along  the  director.  When  the 
sinus  takes  a  straight  or  oblique  direction  downward,  the  or- 
dinary grooved  director  cannot  be  made  to  follow  it.  In  order 
to  overcome  this  difficulty  the  author  has  devised  a  probe- 
pointed,  angular  grooved  director  (Fig.  81),  which  greatly 
simpHfies  the  procedure.  It  consists  of  a  handle,  about  five 
inches  (12.70  centimeters)  long,  to  which  a  probe-pointed 
grooved  director,  two  inches  (5.08  centimeters)  in  length, 
is  joined  at  an  acute  angle  (Fig.  81),  the  whole  instrument 
being  made  of  steel,  which  insures  strength  and  durability.  It 
is  used  as  follows :  First  pass  it  up  the  rectum  until  the  probe- 
point  rests  just  above  the  opening  in  the  bowel  (Fig.  82) ; 
then  pass  it  into  the  tract  and  pull  downward  until  it  bulges 
out  the  skin  (Fig.  83) ;    an  incision  is  then  made  at  this  point 


Fig.  81. — Gant's  Angular  Grooved  Director  for  Blind  Internal  Fistula. 

and  the  director  pulled  well  down.  The  index  finger  of  the 
left  hand  is  passed  into  the  rectum  until  the  internal  end  of  the 
director  is  grasped,  when  it  is  drawn  down  and  out  of  the  bowel 
where  it  lies  directly  across  the  anus  (Fig.  84)  until  the  tissues 
resting  upon  it  have  been  divided  and  the  operation  completed  as 
in  complete  fistula. 

For  Complete  External  Fistula  the  operation  is  very  simple. 
It  consists  in  introducing  the  straight  director  into  the  open- 
ing farthest  from  the  anus  and  out  at  the  other,  and  then 
quickly  severing  the  intervening  tissues. 

In  Complete  Internal  Fistula  the  procedure  is  very  similar  to 
that  just  described,  but  a  speculum  is  necessary  to  find  the 
openings  and  adjust  the  director. 

Horseshoe  Fistula  (Figs.  85,  87,  and  91)  gives  the  surgeon 
an  opportunity  to  display  his  ingenuity  in  performing  the 
operation  as  it  should  be  done,  namely:  all  the  sinuses 
between  the  external  openings  should  be  laid  open  first,  then 


262 


DISEASES  OF  THE  RECTUM  AXD  ANUS 


made  to  communicate  with  the  rectum  by  dividing  the  main 
sinus  (Figs.  86,  88,  and  92).  In  this  way  the  sphincter  is  severed 
but  once,  and  there  is  httle  danger  of  incontinence  following 
the  operation.  On  the  other  hand,  if  the  director  is  passed 
into  each  of  the  outer  openings,  then  forced  into  the  rectum 
and  the  tissues  divided  once  for  each  opening,  the  sphincier 
will  be  cut  two  or  more  times,  and  the  danger  of  incontinence 
is  materially  increased. 

In  Complex  Fistula,  where  there  are  multiple  openings  both 


Fig.  82.— Method  of  Using  Ganf  s  Angular  Grooved  Director.     First  Step. 


upon  the  surface  and  in  the  rectum,  it  is  sometimes  necessary 
to  cut  the  sphincter  in  more  than  one  place.  It  has  been  the 
author's  experience  that  incontinence  rarely  follows  the  division 
operation  when  properly  done.  The  author  recently  operated 
upon  a  woman  who  had  37  openings  scattered  over  the  buttocks, 
5  in  the  vulva,  3  in  the  vagina,  and  3  in  the  rectum.  All  the 
sinuses  were  laid  open  and,  in  doing  this,  the  sphincter-muscles 
were  divided  at  three  points.  At  the  end  of  three  months  the 
wounds  had  entirely  healed  and  she  retained  perfect  control  over 
the  bowel.     A  surprising  thing  in  complex  fistulae  is  that,  in  pro- 


TREATMENT  OF  AXO-RECTAL  FISTULA 


263 


portion  to  the  number  and  extent  of  the  incisions,  but  a  smah 
amount  of  scar-tissue  remains  after  heaHng. 

Recto-vaginal  Fistula  has  been  the  subject  of  much  friendly 
discussion  between  the  proctologist  and  the  gynecologist,  each 
claiming  that  it  is  a  part  of  his  work.  It  has  been  the  custom 
of  the  writer  to  treat  all  such  cases  applying  to  him  for  rehef, 
and  he  is  wilHng  to  concede  the  same  privilege  to  his  gyneco- 
logic confreres.  This  form  of  fistula  can  sometimes  be  cured, 
especially  when  the  opening  is  small,  by  keeping  the  rectum 


Fig.  83.— Method  of  Using  Gant's  Grooved  Director.     Second  Step. 

and  vagina  clean  and  cauterizing  the  sinus  with  the  actual 
cautery  or  stick  silver  as  many  times  as  may  be  necessary. 
When  the  opening  between  the  rectum  and  vagina  is  large  and 
high  up,  operative  procedure  must  be  resorted  to.  In  some 
cases  the  sinus  will  heal  by  granulation  after  simple  incision 
and  curettage.  The  best  results,  however,  have  followed  when 
the  sinus  has  been  dissected  out  and  the  rectal  and  vaginal 
surfaces  closed  by  separate  rows  of  sutures.  In  doing  this 
operation  it  is  necessary  to  split  the  recto-vaginal  septum,  care 


264 


DISEASES  OF  THE  RECTUM  AND  ANUS 


being  taken  to  avoid  removing  more  tissue  than  is  absolutely 
necessary. 

In  Recto-vulvar  and  Recto-labial  Pistulse  the  sinus  may  be 
laid  open  by  an  incision  at  a  right  angle  to  the  sphincter,  after 
which  the  tract  is  dissected  out;  the  wound  is  closed  by  buried 
sutures  and  the  sphincter  united  as  in  perineorrhaphy.  This 
form  of  fistula  may  sometimes  be  cured  by:  (a)  laying  the 
sinus  open  and  allowing  it  to  heal  by  granulation ;  (b)  passing 
an  elastic  ligature  through  the  sinus  and  tying  it  so  as  to  in- 
clude all  of  the  tissue  within  its  grasp,  after  which  it  is  allowed 


Fig.  84. —Method  of  Using  Gant's  Grooved  Director.    Third  Step. 


to  cut  its  way  out;  or  (c)  keeping  it  clean  and  cauterizing  its 
walls,  as  often  as  may  be  necessary,  with  stick  silver. 

Eecto-veslcal  Fistula  rarely  heals  spontaneously.  The  opera- 
tions for  the  relief  of  this  condition,  when  congenital,  have 
been  discussed  elsewhere.  When  due  to  stricture,  tubercular 
or  malignant  disease,  very  little  can  be  accomplished  by  local 
operations,  and,  the  sooner  a  colostomy  is  made,  the  better  it 
will  be  for  the  sufferer.  An  artificial  anus  gives  marked  relief 
and  frequently  an  extension  of  life  by  permitting  free  exit  of 
the  feces,  thus  preventing  their  entrance  to  the  bladder  and 
urethra  and  obviating  the  suffering. 

Recto-vesical  fistula  can  be  cured  occasionally  by  irriga- 


TREATMENT  OF  ANORECTAL  FISTULA 


265 


tion  of  both  bladder  and  rectum,  cauterization,  regulating  the 
stools,  keeping  a  tube  in  the  rectum  to  prevent  an  accumula- 
tion of  gases,  and  by  retaining  a  catheter  in  the  bladder  through 
which  the  urine  may  escape.  When  palliative  measures  have 
been  tried  in  vain,  a  plastic  operation  is  indicated,  especially 
where  the  opening  is  large. 

There  are  several  steps  in  the  operation,  and  they  are  as 
follows:  (a)  thoroughly  divulse  the  sphincter;  (b)  expose  the 
rectal  end  of  the  sinus  by  means  of  a  long-bladed  operating 
speculum;  (c)  trim  the  edges  of  the  opening;  (d)  close  the 
wound  by  deep  silver  or  chromicized  catgut  sutures,  including 
all  the  rectal  and  vesical  coats  except  the  mucosa  of  the  latter; 
(e)  place  a  catheter  in  the  bladder  and  a  tube  in  the  rectum. 
Goodsall  and  Miles  advise  placing  the  sutures  one-eighth  of  an 


Fig.  85.— Simple  Horseshoe  Fistula 
Before  Operation. 


c^^.^^ 


Fig.   86. — Appearance  of  Wound 
After  Operation. 


inch  (31  millimeters)  apart,  and  extending  them  for  a  consid- 
erable distance  beyond  the  angles  of  the  wound. 

When  the  recto-vesical  sinus  is  high  up,  the  abdomen 
should  be  opened  and  the  operation  performed  from  above. 

Recto-urethral  Fistula  is  extremely  difficult  to  cure.  Many 
remedies  and  operations  have  been  suggested  for  the  relief  of 
this  condition,  but  none  of  them  has  met  with  any  great  degree 
of  success.  The  best  motto  in  these  cases  is  perseverance ;  when 
one  procedure  fails  another  should  be  tried,  and  still  another 
until  the  right  one  is  found.  It  is  always  necessary  in  these 
cases  to  "tie  the  bowels  up"  and  to  keep  the  bladder  empty 
by  interrupted  or  continued  catheterization.  A  cure  may  be 
attempted  by  applying  silver  nitrate,  zinc  chloride,  or  the 
Paquelin  cautery  to  the  sinus ;  or  the  latter  may  be  dilated  and 


266 


DISEASES  OF  THE  RECTUM  AND  ANUS 


curetted,  or  slit  up  and  allowed  to  heal  by  granulation.  Again, 
the  sphincters  may  be  divulsed,  the  opening  in  the  rectum  ex- 
posed, and  the  edges  freshened  and  sutured,  leaving  the  ure- 
thral end  of  the  sinus  to  heal  by  granulation.  Ziembieki  ad- 
vises freeing  the  lower  rectum,  closing  the  opening  within,  and 
then  rotating  the  bowel  until  the  rectal  and  urethral  openings 
are  left  some  distance  apart :  an  arrangement  which  prevents 
the  escape  of  gas  and  feces  into  the  urethra  and  of  urine  into 
the  rectum.  Tuttle  has  operated  successfully  three  times  as 
follows:   (a)  incise  the  sphincter-muscle;   (b)  cut  away  scar- 


/;%. 


s.n  \ 


Fig.  87. — Complex  Horseshoe  Fistula 
Before  Operation. 


Fig.  88. — Appearance  of  Wound  After 
Operation,  the  Sphincter-muscle  being 
Cut  but  Once. 


tissue  and  freshen  both  ends  of  the  sinus ;  (c)  free  the  anterior 
rectal  wall  to  three-fourths  of  an  inch  (1.9  centimeters)  above 
the  fistula  and  laterally  for  half  an  inch  (1.27  centimeters);  (d) 
if  there  is  a  stricture,  correct  it  by  perineal  section;  (e)  take 
flap  from  either  side  of  the  urethra  to  replace  the  part  de- 
stroyed, and  unite  them  with  catgut  over  a  sound ;  (f)  with- 
draw the  sound  and  leave  the  perineal  wound  and  anterior 
urethral  incision  unsutured ;  (g)  close  the  edges  of  the  bowel- 
wound  with  chromicized  catgut;  (h)  place  a  drainage-tube  in 
the  rectum  and  pack  iodoform  gauze  around  it;   (i)  leave  a 


TREATMENT  OF  ANORECTAL  FISTULA  267 

<:atheter  in  the  bladder;  (j)  pack  the  perineal  wound  with  ab- 
sorbent cotton  and  hold  it  in  position  with  a  T-bandage. 

In  cases  where  the  opening  is  large  and  a  considerable 
amount  of  feces  escapes  into  the  urethra,  causing  intense  suf- 
fering, an  artificial  anus  should  be  made  at  once,  provided  less 
radical  measures  have  failed  to  give  relief.  The  dangers  of 
this  operation  are  slight  and  the  benefits  instantaneous.  After 
the  fecal  current  has  been  checked,  renewed  efforts  should  be 
made  to  cure  the  fistula,  and,  if  successful,  the  colostomy  open- 
ing can  be  closed. 

AFTER=TREATMENT 

Many  of  the  failures  following  operations  for  fistula  in  ano 
are  due  to  careless  and  improper  management  of  the  wound. 
Immediately  after  the  operation  the  wound  should  be  packed 
tightly  with  gauze  to  control  hemorrhage  (Fig.  89.)  This 
dressing  is  left  in  situ  for  twenty-four  hours,  after  which  time 


Fig.   89.— Small  Darmack  Gauze-carrier,   Suitable  Size  for  Packing  Large 
and  Deep  Fistulous  Sinuses. 

it  should  be  removed,  because  it  will  be  hard  and  dry,  or  satu- 
rated with  the  discharge.  The  gauze  can  be  removed  without 
causing  much  pain,  by  allowing  a  stream  of  bichloride  or  car- 
bolic-acid solution  to  play  upon  it  until  it  is  soft.  The  wound 
should  then  be  irrigated  with  sterile  water  or  a  rehable  anti- 
septic solution,  and  dried,  after  which  sterile  gauze  or  that 
containing  iodoform,  balsam  of  Peru,  or  ichthyol,  must  be 
placed  loosely  in  the  bottom  of  the  sinus.  The  author  has  many 
times  seen  healthy  granulations  arrested  by  packing  the  zvoiind 
too  tightly  and  by  meddling  zuith  or  changing  the  dressing  too  fre- 
quently. The  dressings  require  to  be  changed  only  when  soiled 
by  the  secretions,  and  this  may  be  once  daily,  twice  daily,  or 
only  once  in  two  or  three  days.  The  most  important  thing  in 
the  after-treatment  is  to  see  that  the  sinus  heals  up  from  the 
bottom.  In  many  cases  there  is  a  tendency  for  the  tissues  to 
bridge  over  near  the  anus,  leaving  a  channel  below ;  this  bridge 
of  tissue  must  be  broken  up  with,  the  probe.     It  is  well,  also,  to 


268  DISEASES  OF  THE  RECTUM  AND  ANUS 

look  out  for  the  formation  of  fresh  sinuses.  They  will  be  indi- 
cated by  rise  in  temperature,  increased  pain,  and  a  more  abundant 
discharge  than  would  be  expected  from  such  a  wound.  When 
new  sinuses  are  found,  they  should  be  laid  open  at  once  and 
treated  in  the  same  mnaner  as  the  original  jQstula.  Because  of  the 
danger  of  infection,  a  fistulous  wound  should  never  he  probed 
unless  there  is  positive  evidence  of  pus-formation  in  the  deeper 
structures. 

When  granulations  are  sluggish  or  arrested,  they  should 
be  stimulated  to  renewed  activity  with  balsam  of  Peru;  silver 
citrate,  lactate,  or  nitrate;  ichthyol,  carbolic  acid,  zinc,  calomel, 
carbolized  oil,  or  zinc  stearate  with  iodoform,  or  by  the  actual 
cautery.  Exuberant  granulations  should  be  destroyed  with  stick 
silver,  caustic  potash,  or  copper  sulphate. 

It  is  frequently  necessary  to  catheterize  these  patients  dur- 
ing the  first  twenty-four  hours  on  account  of  pressure  exerted 
upon  the  urethra  and  irritation  of  the  levator  ani  muscle  by 
the  packing.  During  the  first  day  there  is  considerable  pain, 
especially  when  the  incisions  have  been  extensive;  this  should 
be  relieved  by  hypodermic  injections  of  morphine  as  often  as 
is  required. 

The  diet  for  the  first  few  days  after  these  operatinos  should 
be  nourishing,  but  confined  to  fluid  and  semisolid  foods,  such 
as  6oups,  soft-boiled  eggs,  milk,  etc.  Some  surgeons  maintain 
that  the  bowels  should  be  "tied  up"  for  several  days  after 
fistula  operations  by  the  use  of  opiates,  but  the  author  has 
found  this  unnecessary,  if  the  patient  has  been  properly  pre- 
pared beforehand.  Ordinarily  there  will  be  no  action  before 
the  third  or  fourth  day,  and  sometimes  not  for  a  week;  when 
deferred  longer  than  the  Hfth  day,  a  dose  of  calomel,  castor- 
oil,  salts,  licorice-powder,  or  Carabaha  water  should  be  pre- 
scribed, followed  by  a  soap-suds  enema  to  soften  the  move- 
ment; oil  and  glycerin  may  be  added  to  the  injection  if  the 
stool  is  large,  hard,  and  nodular.  The  patient  may  be  placed 
on  full  diet  after  the  first  week,  for  by  this  time  normal-sized 
stools  can  be  retained  until  the  proper  time  and  then  evacuated 
with  little  pain.  Tubercular  patients,  and  those  who  are  gen- 
erally run  down  from  other  causes,  should  be  given  tonics  and 
required  to  spend  much  of  their  time  in  the  fresh  air  and  sun- 
shine. 


TREATMENT  OF  ANORECTAL  FISTULA  269 

The  after-treatment  in  cases  of  recto-vaginal,  recto-vesical, 
or  recto-urethral  fistula  does  not  differ  from  that  of  ordinary 
fistula,  except  that  it  is  essential  (1)  to  keep  the  patient  abso- 
lutely quiet  for  the  first  few  hours  with  opiates,  (2)  to  confine 
the  bowels  for  a  week  or  more,  (3)  to  place  a  tube  in  the  rec- 
tum so  that  the  gas  may  escape,  and  (4)  in  recto-vesical  and 
recto-urethral  fistula  to  keep  the  bladder  empty  by  catheteriza- 
tion. 

The  following  are  the  more  important  rules  to  be  observed 
in  the  treatment  of  fistula  in  ano,  and  are  well  worth  remem- 
bering by  those  who  contemplate  treating  this  disease : — 

1.  Always  operate  under  rigid  aseptic  conditions. 

2.  Operate  on  all  cases  where  there  is  sutficient  vitality 

to  heal  the  wound. 

3.  Be  certain  to  divide  all  sinuses  and  diverticula. 

4.  See  that  the  director  is  not  forced  out  of  the  main  sinus 

into  adjacent  tissues. 

5.  Divide    the    sphincter    at     a     right    angle,     and    not 

oblicjuely. 

6.  Ligate  or  twist  all  spurting  vessels.      ' 

7.  Be  careful  not  to  enter  the  peritoneal  cavity  except  when 

absolutely  necessary. 

8.  Guard  against  injury  to  the  vagina,  bladder,  urethra, 

and  prostate  when  the  sinus  courses  anteriorly  to  the 
rectum. 

9.  Refuse   to   operate   on   persons   in   the   last   stages   of 

phthisis,    diabetes,    Bright's   disease,    and   heart   dis- 
ease. 

10.  Give  these  patients  the  benefit  of  the  sun  and  fresh  air 

as  much  as  possible. 

11.  Avoid  cutting  the  sphincter  more  often  than  is  abso- 

lutely necessary. 

12.  Pack  the  wound  tightly  at  the  time  of  operation  to 

prevent  hemorrhage,   and   loosely  thereafter,   other- 
wise granulations  will  be  arrested. 

13.  Warn  the  patient  of  the  possibility  of  incontinence  fol- 

lozving  the  operation. 

14.  Supply  fistula  patients  with  nourishing  food. 

15.  Destroy  excessive  granulations. 


270  DISEASES  OF  THE  RECTUM  AND  ANUS 

16.  When  a  wound  is  sluggish  and  looks   grayish  and 

greasy,  stimulate  it;   give  patient  a  tonic  when  in- 
dicated. 

17.  Do  not  let  the  wound  bridge  over,  but  make  it  heal 

solidly  from  the  bottom. 

18.  Be  guarded  in  making  a  prognosis  as  to  the  time 

required  to  effect  a  cure. 

19.  Correct  any  disease  of  the  rectum  which  might  result 

in  the  formation  of  a  new  sinus. 

20.  Resort  to  skin-grafting  where  the  cutting  has  been 

extensive  and  the  skin  does  not  seem  inclined  to 
extend  across  the  wounds. 

21.  Fistula  patients  having  lung  involvement   should  be 

sent  to  a  proper  altitude  as  soon  as  the  wound  has 
healed. 

22.  Mo.st  of  all,  remember  that  success  depends  more  npon  the 

after-treatment  than  upon  the  operation. 


ILLUSTRATIVE  CASES 
Case  VI.  Complex  Fistula  with  Forty-eight  Openings:  Thirty-seven 
•upon  the  Buttocks,  Five  in  the  Vulva,  and  Three  In  the  Vagina,  and  Thie^ 
in  the  Rectum. — Mrs.  H.,  aged  40,  came  to  my  clinic  at  the  New  York  Post- 
graduate Hospital  to  be  treated  for  fistula,  and  gave  the  following  history: 
Family  history  good  except  that  one  brother  died  of  asthma.  Patient  gave  no 
evidence  of  syphilis  or  tuberculosis.  She  complained  of  a  continual  discharge 
of  pus  and  blood  from  the  rectum.  Twenty-five  years  before  she  noticed  a  pain- 
ful swel  ing  in  the  perineum,  but  this  did  not  open.  Seven  years  later  a  second 
swelling  appeared  at  the  left  side  of  the  anus  and  opened,  resulting  in  fistula. 
Her  physician  advised  her  not  to  have  an  operation.  From  that  time  up  to  the 
present  abscesses  formed  and  opened  at  short  intervals  until  the  "holes"  were 
so  numerous  that  she  had  lost  count  of  them.  The  discharge  from  the  sinuses 
was  abundant,  had  a  foul  odor,  and  kept  the  nates  continually  chafed  to  such 
an  extent  that  walking  was  extremely  painful. 

Exaniinntion  showed  that  the  buttocks  were  discolored  for  several  inches 
around  the  anus.  The  skin  of  the  ano-gluteal  region  was  much  thickened 
and  excoriated.  As  a  result  of  chronic  inflammation  there  was  an  eleplian- 
iiasis,  irregular  in  shape,  involving  the  entire  vulva  and  extending  to  the  anus. 
Openings  were  to  be  seen  in  every  direction,  some  at  the  anal  margin,  others 
far  out  upon  the  buttocks  and  several  about  the  vulva,  giving  to  the  parts 
the  appearance  of  having  been  perforated  by  a  lead  of  buckshot.  Probing  and 
injection  of  peroxide  of  hydrogen  revealed  thirt^^-seven  openings  upon  the  but- 
tocks, eight  in  the  vulva  and  vagina,  and  three  in  the  rectum,  and  many  sin- 
uses radiating  in  every  direction  and  apparently  arranged  in  tiers.  In  fact,  the 
skin  was  so  undermined  that,  when  2>eroxide  of  hydrogen  was  forced  through 
one  opening,  it  bubbled  out  at  more  than  a  dozen  difi'erent  places.      Pressure 


TREATMENT  OF  ANO-RECTAL  FISTULA 


271 


in  the  rectum  or  at  any  point  in  the  ano-gluteal  region  caused  excruciating 
pain,  and  forced  out  of  the  sinuses  a  rather  thin,  blood-stained  discliarge. 

The  patient  was  placed  in  the  hospital  and  prepared  in  the  usual  way 
for  the  opera tioHj  which  was  as  follows:  One  of  the  main  sinuses  was  laid 
open  and  curetted,  and  a  search  made  for  branch  sinuses.  These  and  their 
branches  were  treated  in  the  same  manner.  Following  out  this  general  plan 
the  operation  proceeded  until  all  of  the  sinuses,  superficial  and  deep,  were 
divided  except  two  which  ran  high  up  into  the  pelvis,  and  these,  because  of 
the  danger  of  injuring  the  peritoneum,  were  curetted  and  cauterized.  During 
the  operation  it  was  necessary  to  divide  the  sphincter-muscle  in  three  places 
and  remove  large  pieces  of  the  undermined  skin,  leaving  only  that  having  a 
sufficient  blood-supply.     Some  idea  of  the  extent  of  the  raw  surface  left  may 


Fig.  90. 


-Appearance  of  Wounds  Three  Weel<s  After  Operation  in  Case  of 
Multiple  Fistulas  with  Extensive  Burrowing. 


be  had  from  the  accompanying  photograph  (Fig.  90),  taken  three  weeks  after 
the  operation,  when,  as  a  result  of  healing,  its  size  had  diminished  one-third. 
The  wound  was  irrigated  daily  and  dressed  with  sterile  gauze;  the  deep 
sinuses  were  packed  loosely  with  gauze  moistened  with  lO-per-cent.  ichthyol 
solution.  The  wounds  healed  nicely,  and  the  patient  had  made  a  complete 
recovery,  and  was  discharged  from  the  hospital  at  the  end  of  seven  weeks. 

Case  VII.  Horseshoe  Fistula. — Mr.  L.,  aged  38  years,  farmer,  came 
under  my  care  suffering  from  a  fistula.  He  attributed  its  origin  to  an  injury, 
received  from  a  fall  upon  the  frozen  ground,  that  gave  rise  to  an  abscess  which 
pained  him  a  great  deal  for  several  days.  He  applied  poultices,  the  abscess 
pointed,  and  was  lanced  on  the  eighth  day,  and  the  pus  evacuated.  Tlie  in- 
cision was  too  small,  and  in  spite  of  fresh  poultices  it  closed  again.     The  pain 


272 


DISEASES  OF  THE  RECTUM  AND  ANUS 


and  throbbing  returned  for  a  few  days,  when  the  abscess  burst,  and  a  large 
quantity  of' pus  escaped.  This  occurred  a  number  of  times;  each  time  the 
opening  closed  a  new  abscess  formed,  and  new  openings  appeared  on  the  but- 
tocks above  and  in  front  of  the  anus  in  the  perineum.  During  this  time  his 
suffering  had  been  very  great,  notwithstanding  the  fact  that  he  had  used  many 
medicines,  lotions,  and  ointments.  A  surgeon  proposed  an  operation,  but  this 
was  refused,  because  the  patient  did  not  Avant  to  be  confined  to  bed.  At 
length  his  suffering  became  so  great  that  he  submitted  to  proper  treatment. 
When  first  seen  his  general  health  was  good,  and  he  complained  of  nothing 
except  the  pain  and  itching  caused  by  the  discharge,  which  kept  the  parts  about 
the  anus  irritated.     The  skin  immediately  surrounding  the  openings  was  of  a 


Fig.  91. — Horseshoe  Fistula  with  Multiple  Openings. 


dull,  purplish-red  color,  and  the  indurated  fistulous  sinus  could  be  easily  traced 
along  the  subcutaneous  tissues  with  the  finger;  there  Avere  five  well-marked 
openings  (Fig.  91):  two  in  the  perineum,  two  on  the  left  buttock,  and  one 
on  the  right  buttock;  one  of  the  perineal  openings  was  just  below  the  scrotal 
attachment  near  the  center,  the  other  was  one  inch  (2.54  centimeters)  below 
and  a  little  to  the  left  of  the  upper  one.  One  of  the  openings  on  the  left 
buttock  was  one  and  a  half  inches  (3.76  centimeters)  from  and  a  little  above 
the  anus,  while  the  other  was  below  and  about  one  inch  (2.54  centimeters) 
from  the  anus.  The  opening  (Fig.  91)  on  the  right  side  was  situated  far  out 
on  the  buttock,  about  five  inches  (12.7  centimeters)  from  the  anus.  Exami- 
nation  showed   that   the    perineal    openings    communicated   with    each    other 


TREATMENT  OF  ANO-RECTAL  FISTULA 


273 


and  witli  the  openings  upon  the  left  buttock,  but  none  communicated  with 
the  rectum;  and,  further,  that  the  one  on  the  right  side  communicated  with 
the  bowel,  for  a  probe  could  be  passed  through  the  outer  opening  and  into 
the  rectum  at  least  two  inches  (5  centimeters)  above  the  anus.  Digital  ex- 
amination revealed  the  presence  of  a  firm,  fibrous,  or  cartilaginous  band  about 
an  inch  (2.54  centimeters)  thick,  extending  across  the  rectum  nearly  two 
inches  (5  centimeters)  above  the  anus.  The  patient  was  ordered  to  take  a 
bath;  two  teaspoonfuls  of  licorice-powder  were  administered  at  once,  and  an 
injection  given  on  the  following  day,  one  hour  previous  to  the  time  set  for 
the  operation.  The  parts  having  been  previously  shaved  and  the  patient 
thoroughly  anesthetized,  a  grooved  director  was  passed  from  one  perineal  open- 


Fig.  92. — Horseshoe  Fistula.  The  Lines  of  Incisions  Show  how  the  External 
Sinuses  were  Made  to  Communicate  with  Each  Other  and  with  the  Rec- 
tum, and  the  Sphincters  Severed  but  Once,  and  then  at  Right  Angle. 


ing  to  the  other  and  all  intervening  tissues  were  divided.  Then  the  sinus  ex- 
tending thence  to  the  upper  opening  on  the  left  buttock  was  divided,  after 
which  the  director  was  easily  made  to  pass  into  and  through  the  lower  opening 
on  the  same  side,  which  was  treated  in  a  similar  manner.  A  careful  search 
M'as  made  to  see  if  there  were  any  communication  with  the  bowel,  but,  as 
none  could  be  located,  attention  was  directed  to  the  opening  on  the  right 
buttock.  It  was  found  that  an  ordinary  grooved  director  was  far  too  short 
to  reach  from  the  external  opening  into  the  bowel.  Therefore  a  long,  strong, 
steel  director  was  selected  and  passed  into  the  external  and  through  the  internal 
opening  within  the  bowel,  where  it  could  be  felt  with  the  index  finger  of  the 
left  hand  introduced  for  that  purpose.     It  was  found  that  the  tissues  to  be 

18 


274  DISEASES  OF  THE  RECTUM  AND  ANUS 

divided  were  so  firm  and  thick  that  the  internal  end  of  the  director  could  not 
be  brought  outside  the  anus  as  in  ordinary  cases.  A  strong,  sharp-pointed 
bistoury  was  then  passed  along  the  director  until  it  could  be  felt  in  the 
bowel,  when  it  was  pressed  into  a  piece  of  pine  stick  to  prevent  its  doing  any 
damage.  The  knife  and  stick  were  then  withdrawn  at  the  same  time,  dividing 
all  tissues  between  them.  A  short  sinus  running  at  right  angles  to  the  main 
one  was  found  and  divided.  Thus  all  the  sinuses  were  made  to  communicate 
with  each  other  (Fig.  92). 

When  all  had  been  divided  they  were  curetted,  and  Salmon's  back-cut 
made  along  the  back  of  each.  After  this  they  were  irrigated  and  tightly 
packed  with  iodoform  gauze  and  cotton,  and  the  patient  ordered  to  bed  with 
instructions  to  have  an  hypodermic  injection  of  V4  grain  (0.015  gram)  of 
morphine,  in  case  he  suffered  much  pain  the  first  night.  The  dressings  were 
not  changed  until  the  second  day.  Thereafter  the  dressings  were  changed 
every  other  day  for  three  weeks,  at  the  end  of  which  time  all  the  wounds 
were  completely  healed,  and  the  patient  went  to  his  home  well  and  happy. 

Case  VIII.  Blind  Internal  Fistula. — A  lady  was  sent  to  me  from  Kansas 
to  be  treated  for  some  rectal  trouble  with  the  following  symptoms:  She  had 
been  constipated  for  several  years;  never  had  more  than  two  actions  a  week, 
and  then  strong  purgatives  were  necessary.  She  was  nervous  and  sufi'ered 
almost  constant  pain  in  the  rectum,  which  was  very  much  worse  during  and 
after  defecation.  The  pains  were  sometimes  reflected  up  the  back  and  down 
the  limbs.  There  was  no  bleeding  at  any  time,  and  very  little  discharge.  On 
examination  the  rectum  and  anus  seemed  perfectly  healthy,  except  that  the 
sphincter  was  tightly  contracted  and  very  much  thickened.  I  came  to  the 
conclusion  that  her  trouble  was  due  largely  to  constipation  and  the  feces  be- 
coming impacted  and  pressing  upon  the  nerves,  which  caused  a  reflex  spasm  of 
the  sphincter  and  the  coincident  pain.  After  divulsion,  a  large-sized  Gant  specu- 
lum was  introduced  and  a  careful  examination  was  made  of  the  rectum,  which 
revealed  the  presence  of  a  small  inflamed  area  about  one  inch  (2.54  centimeters) 
above  the  anus,  in  the  center  of  which  was  a  little  pocket  formed  by  the  trans- 
verse folds  of  the  mucous  membrane.  A  small  probe  was  pressed  first  in  one 
place  and  then  in  another  until  an  opening  and  sinus  were  found  which  passed 
downward  beneath  the  mucous  membrane  and  sphincter-muscle  and  skin  to  a 
point  one  inch  (2.54  centimeters)  below  and  a  little  to  the  left  of  the  anus.  The 
author's  angular  grooved  director  was  then  made  to  take  the  place  of  the  probe, 
and  was  pressed  downward  against  the  skin.  An  incision  was  made  over  the 
point,  and  it  was  forced  through  the  skin,  and  all  the  tissues  thereon  divided. 
The  wound  was  treated  as  after  an  ordinary  operation  for  complete  fistula,  and 
the  patient  was  perfectly  well  at  the  end  of  three  weeks.  This  case  is  reported 
simply  because  it  shows  how  easily  a  mistaken  diagnosis  may  be  made  unless 
extraordinary  care  is  observed  in  making  an  examination. 

For  Literature  on  Fistula  in  Ano,  see  pages  284  and  285. 


CHAPTER  XIX 

THE  RELATION  OF  PHTHISIS  PULflONALIS  TO 
FISTULA  IN  ANO 

This  subject  is  of  great  importance,  but  is  little  under- 
stood, and  therefore  deserves  special  consideration.  The  rectal 
surgeon  is  frequently  called  upon  to  treat  fistula  in  patients 
whose  condition  is  aggravated  by  coughing,  the  result  of  lung 
involvement ;  the  general  practitioner  likewise  attends  many 
phthisic  patients  who  fail  to  improve  under  the  very  best  treat- 
ment because  of  an  exhausting  discharge  from  an  anal  fistula. 

Fistula  and  pJithisis  occur  in  the  same  individual  with  a 
regularity  that  cannot  be  explained  by  mere  coincidence.  In 
order  to  show  the  proportion  of  fistula  to  phthisis  Allingham 
reports  1632  cases  of  fistula  operated  upon,  and  of  this  number 
no  less  than  234  had  phthisis. 

In  order  to  ascertain  the  proportion  of  persons  suffering 
coincidently  from  incipient  phthisis  and  fistula  in  ano,  and  also 
the  manner  in  which  fistulse  complicated  by  phthisis  are  treated 
in  the  Loomis  Sanitarium,  the  author  addressed  a  letter  of  in- 
quiry to  Dr.  J.  Edward  Stubbert,  manager  of  that  most  excel- 
lent and  deserving  institution,  and  the  following  is  his  reply: — ■ 

Liberty,  N.  Y.,  April  2,  1901. 
Dr.  Samuel  G.  Gant,  58  West  5Gth  Street,  N.  Y. 

Dear  Doctor:  We  have  had  very  few  cases  of  fistula  in  ano.  There 
have  been  595  cases  admitted  to  this  sanitarium,  and  among  these  only  9  have 
shown  fistula  in  ano.  Of  these  9,  1  has  just  entered,  and,  therefore,  we  have 
not  worked  him  up  in  the  statistics  yet.  Counting  the  8  cases,  the  percentage 
of  595  cases  shows  that  1  Vs  per  cent,  suffered  from  this  disease,  and  100  per 
cent,  of  those  operated  upon  loere  permanently  cured.  The  method  of  opera- 
tion in  all  eases  but  one  has  been  laying  open  the  fistula,  curetting,  and  packing 
with  gauze  soaked  in  a  10-per-cent.  solution  of  ichthyol.  My  directions  to  the 
house  surgeon  in  these  eases  were  to  increase  the  strength  of  the  ichthyol 
until  a  caustic  efiect  was  produced,  if  necessary;  but  he  reports  that  10  per 
cent,  was  sufficient  in  all  these  cases. 

It  is  our  practice  here  to  operate  on  every  case  that  comes  in,  regardless 

(275) 


276  DISEASES  OF  THE  RECTUM  AND  ANUS 

of  the  statement  made  hy  some,  that  the  effect  of  such  an  operation  would  he 
to  increase  the  primary  trouble  in  the  lungs.  In  no  instance,  however,  has  this 
happened;  on  the  contrary,  the  closing  of  the  fistula  seems  to  have  acted  hene- 
ficially  on  the  tubercular  process  in  the  lungs? 

Trusting  that  this  meager  information  will  be  of  some  use,  I  remain. 

Yours  fraternally, 

[Signed]  J.  Edwakd  Stubbekt. 

(Dictated— G.) 


Walsham,  Assistant  Physician  to  the  City  of  London  Hos- 
pital for  Diseases  of  the  Chest,  in  a  report  made  to  Goodsall 
and  Miles  on  the  frequency  of  fistula  as  a  complication  of 
phthisis,  says : — 

Out  of  891  cases  of  pulmonary  tuberculosis  that  have  been  under  treat- 
ment in  my  out-patient  room  during  the  last  three  years,  I  have  had  5  cases 
of  fistula  in  ano  and  2  cases  of  ischio-rectal  abscess,  all  in  males,  aged  55,  49, 
52,  41,  37,  42,  and  41,  respectively. 

In  the  2  with  ischio-rectal  abscess  the  physical  signs  in  the  chest  were 
slight.  Of  the  5  with  fistula  in  ano,  in  2  the  physical  signs  were  slight;  in  the 
other  3  the  disease  was  far  advanced. 

Out  of  133  post-mortem  examinations,  made  by  myself  on  persons  dead 
of  pulmonary  tuberculosis,  I  found  fistula  in  ano  in  only  I  case. 

Dr.  Edward  Wells,  of  Chicago,  states  that,  in  the  Bromp- 
ton  Hospital  for  Consumption,  anal  fistula  occurred  in  4  per 
cent,  of  8000  cases,  but  that  in  a  later  series  of  cases  it  ap- 
peared in  only  1  per  cent.  At  the  Loomis  Sanitarium  for 
incipient  phthisis,  out  of  the  595  cases  admitted,  9  suffered  from 
fistula  in  ano. 

Dr.  Alfred  Meyer,  of  New  York,  has  recently  published 
the  following  statistics  bearing  upon  this  subject: — 

"The  records  of  the  medical  service  at  Mount  Sinai  Hos- 
pital for  the  past  ten  years  show  460  cases  of  phthisis,  4  of 
whom  had  fistula  in  ano,  or  0.87  per  cent.  On  the  surgical 
service,  on  the  contrary,  out  of  139  cases  of  fistula  in  ano,  13 
were  reported  with  more  or  less  definite  physical  signs  of  pul- 
monary tuberculosis,  or  9.3  per  cent. 

"For  comparison  I  should  like  to  append  the  following 
cases  which  I  have  gathered  from  other  institutions : — 


1  Italics  by  the  author. 


!  RELATION  OF  PHTHISIS  PULMONALIS  TO  FISTULA  277 

No.  of  Cases  of 
Reporter  Institution  Plithisis       Fistula 

Cauldwell St.  Joseph's  Home 3000  30 

Fraenkel Montefiore  Home    69  2 

Author   Bedford  Sanitarium   30  0 

Trudeau Saranac   Lake    100  3 

Dunham Massachusetts  Hospital  for  Consumptives 550  15 

3749  50 

"In  my  judgment,  these  figures  illustrate  strikmgiy  the 
cause  of  the  differences  of  opinion  heretofore  prevalent,  a  dif- 
ference due  entirely  to  the  source  of  the  experience,  whether 
medical  or  surgical." 

From  an  analysis  of  the  statistics  of  others,  together  with 
his  own,  the  author  has  arrived  at  the  conclusion  that  from  4 
to  6  per  cent,  of  all  phthisic  patients  suffer  from  fistula,  while 
a  much  larger  percentage  of  those  afflicted  with  fistula  have 
phthisis.  It  is  extremely  difficult  to  arrive  at  the  correct  ratio 
of  one  disease  to  the  other;  for  instance,  a  patient  going  to 
his  family  physician  for  a  lung  complaint  does  not  deem  it 
necessary  to  tell  him  that  he  has  a  fistula.  On  the  other  hand, 
when  a  patient  goes  to  the  surgeon  to  have  a  fistula  cured, 
the  latter  will  at  once  suspect  lung  involvement  because  of  the 
patient's  cough  and  general  debilitated  condition.  The  ma- 
jority of  medical  and  surgical  writers  not  long  since  believed 
there  was  some  anatomic  or  pathologic  connection  between 
anal  fistula  and  the  lungs,  and  as  a  result  advised  against  opera- 
tion for  the  cure  of  fistula.,  They  maintained  that,  in  case  the 
operation  was  successful  and  the  sinus  healed,  there  wbuld  be 
no  outlet  for  the  discharge;  consequently  the  existing  lung 
trouble  would  be  aggravated,  and  the  patient  would  die.  They 
also  believed  that,  in  case  phthisis  did  not  exist  before  the  cure 
of  fistula,  it  would  develop  as  a  result  of  retained  poison  finding 
its  way  to  the  lungs. 

The  trouble  with  these  gentlemen  was  that  they  had  the 
cart  before  the  horse.  While  the  author  does  not  doubt  that 
phthisis  is  a  frequent  cause  of  fistula,  he  is  extremely  skeptic 
as  to  the  etiologic  relation  of  fistula  to  phthisis.  He  does  not, 
however,  wish  to  convey  the  impression  that  he  beheves  all 
fistulas  are  the  result  of  tuberculous  lung  disease,  for,  in  fact, 
not  more  than  one  in  six  or  eight  is  caused  by  it,  the  remainder 


278  DISEASES  OF  THE  RECTUM  AND  ANUS 

being  the  result  of  abscess  induced  by  exposure,  trauma,  forei'gn 
bodies,  and  pyogenic  bacteria. 

There  are  two  kinds  of  tubercular  fistula:  (1)  true  tuber- 
culous fistulse,  the  result  of  localized  deposits;  (2)  fistulse  in- 
duced or  made  difficult  to  cure  because  of  the  cough  and  low- 
ered vitality,  the  result  of  phthisis. 

1.  True  Tubercular  Fistulse  are  nearly  always  secondary  to 
intestinal  ulceration,  which,  in  turn,  is  secondary  to  tuberculous 
disease  in  some  other  organ,  especially  the  lung.  Tubercle 
bacilli  may  gain  entrance  to  the  intestine  through  the  food, 
but  most  observers  hold  to  the  opinion  that  intestinal  tuber- 
culosis is  the  result  of  swallowing  sputum  containing  tubercle 
bacilli.  It  appears  that  the  vitality  of  the  bacilli  is  not  mate- 
rially interfered  with  by  the  gastric  or  intestinal  contents.  This, 
however,  may  be  partially  explained  by  the  impaired  digestion 
coincident  with  general  tuberculosis. 

2.  Non-tubercular  Fistulse  are  frequent  in  phthisic  patients, 
for  several  reasons :  (a)  persons  having  general  tuberculosis  are 
particularly  prone  to  suppuration  from  slight  causes  ;  (h)  because 
of  the  absence  of  fat  in  the  ischio-rectal  fossa,  large  blood-vessels 
are  left  unsupported  and  readily  become  dilated  and  congested; 
(c)  last,  the  effects  of  constant  coughing  of  phthisic  patients  is 
most  noticeable  at  the  anus,  and  may  result  in  bruising  of  the 
parts,  and  lead  to  abscess  and  fistula. 

DIFFERENTIAL   DIAGNOSIS 

The  symptoms  and  general  characteristics  of  true  tuber- 
cular fistulse  are  so  different  from  those  of  the  ordinary  kind 
that  it  is  not  a  difficult  matter,  if  one  is  careful,  to  differentiate 
between  them,  as  will  be  noticed  from  the  following  compar- 
ison : — 

Table  IX.      Differential  Diagnosis  Between  Tubercular  and 
Non-tubercular  Fistula 
non-tubercular  tubercular 

1.  Internal     and     external     openings      External  and  internal  openings  large 

small  and  round,  the  edges  red,  and  triangular;     edges   of  a   bluish 

and  situated  in  the  center  of  an  tint  and  droop  into  the  opening, 
elevation. 

2.  Buttocks    rounded    and    suppoi-ted  Skin  undermined. 

by  fat. 

3.  Hair  about  the  buttocks  noi-mal.        Hair  abundant,   long,   and  silky. 

4.  Nails  normal.  Nails  clubbed. 


RELATION  OF  PHTHISIS  PULMONALIS  TO  FISTULA  279 

NON-TUBERCULOUS  TUBERCULOUS 

5.  Face,  ears,  and  nose  normal.  Face   pinched;    nostrils   dilated;    ears 

large  and  prominent. 

6.  Voice  natural.  Voice  husky. 

7.  Complexion  ruddy.  Complexion  sallow. 

8.  Rarely  loss  of  flesh.  Loss  of  flesh  considerable  and  rapid. 

9.  Discharge  slight  and  yellow.  Discharge   profuse,   whitish   in   color, 

and  watery. 

10.  Introduction  of  probe  causes  con-       Introduction    of   probe    causes    slight 

siderable  pain.  pain. 

11.  Appetite  normal.  Appetite  poor. 

12.  Digestion  good.  Digestion  bad. 

13.  Sleep  natural.  Sleep     interrupted     and     occasionally 

disturbed  by  night-sweats. 

14.  Discharge      contains      principally       Discharge  contains  tubercle  bacilli. 

colon  bacilli. 

15.  Not   accompanied   by   hemoptysis       Frequently     complicated     by     hemor- 

or  cough.  rhage   of   the   lungs   and   annoying 

cough. 

16.  Tight  sphincter.  Patulous  anus. 

In  examination  of  a  fistula  the  first  and  most  important 
thing  is  to  determine  whether  it  is  simple  or  tubercular  in 
character.  This  point  can  be  settled  by  the  microscopic  dem- 
onstration of  tubercle  bacilli^;  their  presence  in  the  discharge 
is  almost  certain  evidence  of  localized  tuberculosis,  though  it 
should  not  be  forgotten  that  they  are  occasionally  found  when 
tubercular  sputum  has  been  swallowed.  On  the  other  hand, 
there  may  be  tuberculous  disease  and  the  bacilli  may  not  be 
found  in  the  discharge.  When  the  tubercular  process  is  pro- 
gressive and  the  stools  are  watery,  the  bacilli  become  mixed 
with  the  feces,  and  are  then  difficult  to  demonstrate.  To  over- 
come this  difficulty,  Rosenblatt  administers  sufficient  laudanum 
to  produce  hardened  stools,  and  then  microscopically  examines 
the  muco-purulent  discharge  which  adheres  to  the  surface  of 
the  fecal  mass.  In  this  way  he  has  little  difficulty  in  demon- 
strating their  presence.  The  author  has  frequently  had  the  pus 
from  tubercular  fistulas  examined  without  finding  the  bacilli 
of  Koch.  In  such  cases  he  curetted  the  abscess  and  fistula- 
wall  and  had  examined  the  debris.  By  this  procedure  he  never 
failed  to  find  either  them  or  small  caseous  bodies,  which  posi- 
tively proved  the  tubercular  nature  of  the  disease.  When  neither 
is  found,  it  is  safe  to  conclude  that  the  fistula  belongs  to  the 

'See  chaijter  on  examination  for  method  of  finding. 


280  DISEASES  OF  THE  RECTUM  AND  ANUS 

non-tuberculous  type.  Meyer  has  called  attention  to  the  fre- 
quency of  tubercle  bacilli  in  the  rectums  of  phthisic  subjects, 
and  has  also  pointed  out  the  danger  of  mistaking  them  for  the 
smegma  bacillus. 

TREATMENT 

Modern  surgeons  generally  agree  that  the  ordinary  fistula, 
as  found  in  vigorous  persons,  should  be  operated  tipon  and 
the  wound  allowed  to  heal  by  granulation.  There  is,  however, 
some  difference  of  opinion  among  both  physicians  and  sur- 
geons, even  in  this  enlightened  age,  regarding  the  operative 
procedure  for  the  relief  of  tubercular  as  well  as  the  simple  form 
of  fistula  complicated  by  phthisis.  It  has  been  the  custom  of 
the  author  to  operate  on  all  Ustulce,  irrespective  of  their  nature, 
and  the  results  obtained  have  been  equally  satisfactory  to  the 
patients  and  the  operator.  The  vitality  of  the  patient,  and 
not  the  fact  that  he  is  suffering  from  this  or  that  form  of 
fistula,  should  determine  the  necessity  for  an  operation.  The 
author  believes  that  the  surgeon  is  justified  in  operating  upon 
all  cases  of  tubercular  fistula  as  well  as  of  simple  fistula  with 
or  without  lung  complications,  provided  the  general  condition 
of  the  patients  permits.  He  would  not  operate  upon  a  fistula 
in  a  person  who  would  probably  die  of  phthisis  in  the  course 
of  two  or  three  months,  neither  would  he  operate  for  fistula 
in  a  person  similarly  afflicted  with  Bright's  disease.  Each  case 
should  be  a  law  unto  itself,  and  the  treatment,  be  it  non-operative 
or  surgical,  should  be  the  best  for  the  case  in  hand. 

NON=OPERATIVE   TREATMENT 

In  non-operative  cases  the  physician  should  put  forth  his- 
best  efforts  to  make  these  patients  comfortable  and  improve  their 
general  condition.     This  is  accomplished  by: — 

1.  Keeping  the  fistulous  openings  free,  thus  encouraging 
drainage. 

2.  Assisting  healing  and  relieving  pain  by  injections,  or 
the  application  of  caustic,  stimulating,  antiseptic,  and  soothing 
remedies. 

3.  Tempting  the  appetite  and  supplying  palatable  foods, 
known  to  have  nourishing  qualities. 

4.  Stopping  all  medication  which  disturbs  the  stomach  and 
irritates  the  intestine. 


KELATION  OF  PHTHISIS  PULMONALIS  TO  FISTULA  281 

5.  Administering  oils,  creasote,  and  other  medicines  which 
tend  to  improve  the  patient's  general  condition. 

6.  Not  confining  these  patients  in  bed  in  a  dark  room;  on  the 
contrary,  allow  them  fresh  air  and  sunshine;  the  sea-breeze  or 
proper  altitude  when  near  the  mountains. 

7.  Making  things  pleasant  and  cheerful  for  them,  since  their 
lot  in  life  is  not  a  happy  one,  and  their  mental  state  is  occasionally 
pitiable  in  the  extreme. 

8.  Relieving  pain  and  inducing  sleep  by  medication  by  mouth 
or  hypodermic  injection  when  necessary. 

By  following  these  suggestions  these  patients  can  at  least 
be  made  comfortable,  and  a  few  may  be  cured  through  palliative 
measures. 

Anesthetics.— Having  decided  that  an  operation  is  neces- 
sary, a  suitable  anesthetic  should  be  selected.  Local  anesthesia 
should  be  practiced  when  feasible.  Of  local  anesthetics  the 
best  are  sterile  water  or  weak  solutions  of  cocaine  and  eucaine, 
ether-spray,  or  liquid  air.  They  should  be  used  along  the  line 
of  tissue  to  be  incised.  These  agents  lessen,  but  do  not  en- 
tirely abolish,  pain  during  operation.  In  the  selection  of  a 
general  anesthetic  for  this  class  of  cases  chloroform  should 
take  preference  over  ether  or  the  A.  C.  E.  mixture,  because: 
(1)  it  renders  the  patient  unconscious  in  a  shorter  time;  (2) 
patients  recover  from  it  more  quickly;  (3)  there  is  less  vomit- 
ing after  its  use,  thus  obviating  strain  at  the  anus  and  a  pos- 
sible hemorrhage;  (4)  it  does  not  provoke  inflammation  of 
the  lungs  or  kidneys.  Personal  experience  has  forced  the 
author  to  the  conclusion  that  many  of  the  deaths  from  lung 
complications  following  shortly  after  fistula  operation  are  due 
to  a  pneumonitis  excited  by  the  ether  inhaled  during  anesthesia, 
and  not  to  the  operation  or  its  sequels.  He  has  never  had  a 
phthisic  patient  die  shortly  afterward  when  the  operation  was 
performed  under  local  anesthesia. 

SURGICAL  TREATMENT 

Every  effort  should  be  made  to  build  these  patients  up  to 
a  high  standard  before  operating.  The  morning  preceding 
operation  a  mild  laxative  may  be  administered ;  never  strong 
purgatives,  because  they  frequently  start  up  a  diarrhea  difficult 
to  control.  In  other  respects  these  patients  are  prepared  as 
for  any  other  operation.     The  author  will  describe  only  those 


282  DISEASES  OF  THE  RECTUM  AND  ANUS 

operations  best  suited  for  the  class  of  cases  under  discussion. 
Tliey  are  three  in  number:  (1)  ligation,  (2)  division,  and  (3) 
excision. 

Ligation. — The  ligature  operation  consists  in  passing  a  silk, 
wire,  or  elastic  ligature  through  the  sinus  and  out  at  the  anus, 
where  the  ends  are  securely  tied  (Figs.  70,  71,  and  72).  The 
ligature  gradually  cuts  its  way  out,  usually  requiring  from  a 
week  to  ten  days. 

The  following  are  some  of  the  advantages  claimed  for  the 
operation :  (1)  it  does  away  with  the  knife ;  (2)  it  can  be  per- 
formed without  an  anesthetic;  (3)  it  is  comparatively  painless; 
(4)  there  is  no  bleeding;  (5)  the  patient  can  walk  about,  having 
the  benefit  of  the  fresh  air  and  sunshine. 

The  ligature  method  is  not  suited  to  the  treatment  of 
fistulas  in  general,  because  (1)  it  takes  a  longer  time  to  efifect 
a  cure;   (2)  it  does  not  sever  branch  sinuses. 

This  operation,  however,  is  especially  adapted  to  the  treat- 
ment of  tuberculous  fistula  as  well  as  the  simple  variety  com- 
plicated by  phthisis,  since  it  causes  little  pain  and  does  not 
deprive  such  patients  of  the  much-needed  air,  sunshine,  and 
exercise. 

Division. — In  simple  tubercular  fistula,  division  should  be 
performed  under  local  anesthesia.  A  director  of  suitable  size 
is  introduced  through  the  sinus  until  its  tip  can  be  reached  by 
the  finger  in  the  rectum,  when  it  is  pulled  down  and  rests  across 
the  anus.  The  bridge  of  tissue  supported  thereon  is  then  di- 
vided. The  back  part  of  the  sinus  is  next  incised,  and  the  whole 
tract  curetted,  irrigated,  and  packed  with  gauze.  If  the  fistula 
is  of  the  true  tubercular  type,  every  vestige  of  the  involved 
area  should  be  destroyed  with  the  Paquelin  cautery  before 
the  dressings  are  applied.  The  sphincter-muscles  should  be 
handled  very  carefully,  for  it  is  after  these  operations  that  in- 
continence is  likely  to  ensue. 

Excision. —  The  excision  of  fistulous  tracts  is  not  a  popular 
operation,  because  the  results  from  it  are  not  as  satisfactory 
as  from  the  operation  just  described.  It  consists  in  dissecting 
out  the  sinus  and  the  immediate  closure  of  the  wound,  with 
the  object  of  obtaining  primary  union.  Occasionally  it  is  suc- 
cessful; more  often  it  is  a  failure  because  of  infection  through 
the  rectal  end  of  the  wound.  Some  surgeons  maintain  that 
this    operation    is    especially    adapted    to    cases    of    tuberculous 


RELATION  OF  THTHISIS  PULMONALIS  TO   FISTULA  283 

fistula,  because  a  large  suppurating  wound  is  avoided:  a  view 
with  which  the  author  is  entirely  in  accord,  yet  he  would  not 
let  it  take  precedence  over  either  the  ligature  or  division  opera- 
tions. 

The  author  will  close  this  chapter  with  the  following  sum- 
mary and  conclusions : — 

1.  Tubercular  fistula  of  the  anus  is  usually  secondary  to 
tuberculosis  of  the  lungs. 

2.  Pulmonary  phthisis  is  rarely,  if  ever,  secondary  to  fistula 
in  ano,  either  before  or  after  operation. 

3.  Tuberculosis  of  the  anal  region  should  be  dealt  with 
radically,  as  is  recommended  when  it  attacks  other  parts. 

4.  When  the  patient's  general  condition  will  permit,  the 
surgeon  should  operate  on  all  fistulse  irrespective  of  kind. 

5.  The  surgeon  should  not  refuse  to  operate  on  persons 
suffering  from  a  mild  form  of  phthisis,  or  on  those  who  give  a 
family  history  of  tuberculosis.  Certainly,  if  one  destructive 
process  is  arrested,  Nature  is  all  the  more  capable  of  dealing 
with  the  other. 

6.  The  author  believes  that  those  patients  who  rapidly 
decline  and  die  after  operation  under  general  anesthesia  for 
tubercular  fistula  and  non-tubercular  fistula  complicated  by 
phthisis,  do  so  as  the  result  of  a  pneumonitis  induced  by  the  anes- 
thetic, especially  ether.  Such  accidents  have  not  followed  any 
of  the  operations  which  he  has  performed  under  local  anes- 
thesia. 

7.  Finally,  he  believes  that  the  teachings  of  authorities  who 
maintain  that  the  cure  of  a .  fistula  will  result  in  the  develop- 
ment of  phthisis  should  be  discarded  as  erroneous  and  unten- 
able. 

ILLUSTRATIVE  CASES 
Case  IX.  Tubercular  Fistula  (Ligature  Operation). — Mr.  P.  was  re- 
fen-ed  to  me  by  Dr.  Chassagne,  of  Kansas  City,  Mo.,  who  had  been  ti'eating 
him  for  phthisis.  Two  months  pr'or  to  consulting  me  there  formed  on  the 
right  buttock  a  large  abscess,  which  burst  and  resulted  in  a  fistula,  from  which 
a  large  quantity  of  thin,  watery  pus  was  discharged,  which,  when  examined 
microscopically,  was  found  to  contain  tubercle  bacilli.  He  suffered  much  pain, 
was  almost  exhausted,  and  had  the  ordinary  symptoms  of  phthisis:  hemor- 
rhages, cough,  and  nightsweats.  On  examination  the  apices  of  both  lungs 
were  found  to  be  involved.  An  operation  was  decided  upon  and  the  elastic 
ligature  used,  so  that  there  would  be  neither  loss  of  blood  nor  confinement  to 
bed.  Both  the  external  and  internal  openings  being  large,  a  probe  carrying 
the  rubber  ligature  was  easily  passed  through  the  external  opening  into  the 


284  DISEASES  OF  THE  RECTUM  AND  ANUS 

rectum  and  brought  out  at  the  anuSj  thus  including  all  the  tissues  to  be  di- 
vided. The  ligature  was  then  made  taut,  and  the  ends  passed  through  a  piece 
of  lead  with  an  opening  in  the  center.  By  means  of  strong  forceps  the  lead 
was  pressed  together  and  the  ligature  made  secure.  The  whole  procedure  did 
not  take  more  than  five  minutes  and  caused  very  little  pain.  Tonics  and  nutri- 
tious food  were  ordered,  and  the  patient  was  directed  to  spend  all  his  time  in 
the  fresh  air  when  the  weather  would  permit.  In  a  week  the  ligature  had  cut 
its  way  out  and  left  a  healthy,  granulating  sinus,  which  was  dressed  as  after 
the  ordinary  operation  for  fistula.  In  two  months  from  the  time  treatment 
began  the  fistula  was  well  and  the  general  health  had  improved  very  much. 

Case  X.  Tubercular  Fistula  (Division  Operation). — Mr.  J.  C,  aged  27, 
was  referred  to  me  suffering  from  chronic  phthisis  and  from  a  fistula  in  ano, 
the  latter  annoying  him  very  much.  The  discharge  was  very  profuse,  and  kept 
the  surrounding  parts  constantly  irritated.  On  examination  the  fistula  was 
found  to  be  complete;  the  external  opening  was  large  and  to  the  left,  and  one 
inch  (2.54  centimeters)  below  the  anus;  the  opening  in  the  bowel  was  poste- 
riorly between  the  external  and  internal  sphincter-muscles.  The  patient  was 
emaciated,  coughed  considerably,  and  now  and  then  had  night-sweats.  He  had 
been  suffering  from  lung  trouble  for  one  year;  but,  as  there  was  no  immediate 
danger  of  his  dying  from  this  cause,  the  ordinary  operation  for  complete 
fistula  was  decided  on.  The  sinus  was  divided,  curetted,  and  all  of  the  under- 
mined skin  trimmed  off  with  scissors.  The  usual  dressings  were  then  applied 
and  the  patient  put  to  bed  and  surrounded  by  hot  bottles.  There  was  very 
little  shock,  and  on  the  following  morning  the  patient  expressed  himself  as 
feeling  better  than  he  had  for  weeks.  From  this  time  on  there  was  no  increase 
in  the  lung  trouble.  He  was  directed  to  lie  on  a  lounge  in  the  sunshine  daily 
after  the  dressings  had  been  changed  until  the  end  of  ten  days,  which  he  did; 
he  was  subsequently  allowed  to  spend  most  of  his  time  in  the  open  air.  Tonics 
and  creasote  were  given,  and  at  the  end  of  six  weeks  the  sinus  had  completely 
healed.  He  was  finally  advised  to  go  to  El  Paso,  Texas,  for  a  few  months, 
which  he  did.  At  the  end  of  a  year  he  returned  to  his  home  much  improved 
in  general  health,  and  informed  me  that  the  fistula  was  entirely  well.  (Tuber- 
cle bacilli  were  found  in  the  debris  removed  by  the  curette.) 


LITERATURE  OF  ANO-RECTAL  FISTULA 


Auld:    "Fistula  in  Ano,"  Chicago  Clinic,  Sept.,  1900. 

Bacon:    "Fistula  in  Ano,"  Mathews's  Med.  Quart.,  vol.  ii,  p.  110,  1895. 

Bryant:    "Anal  Abscess  and  Fistula,"  Guy's  Hosp.  Reports,  London,  viii,  p.  87, 

1861. 
Cook:    "Treatment  of  Fistula  in  Ano,"  Matlieios's  Med.  Quart.,  vol.  i,  p.  530, 

1894. 
Edwards:    "Rarer  Forms  of  Rectal  Fistula,"  Brit.  Med.  Jour.,  No.  2,  p.  1163, 

1887. 
Esmarch:    "Die  Krankheiten  des  Mastdarmes,"  Stuttgart,  p.  127,  1887. 
Ferguson:    "Treatment  of  Recto-vaginal  Fistula,"  Mathews's  Med.  Quart.,  vol, 

ii,  p.  157,  1895. 


RELATION  OF  PHTHISIS  PULMONALIS  TO  FISTULA  285 

Goodsall  and  Miles:    "Ano-rectal  Fistula,"  "Diseases  of  the  Anus  and  Rectum," 

Pt.  I,  p.  92,  1900. 
Greffrath:     "Beitrage   zur  Operation   der   Mastdarmfisteln,"   Deutsche  Zeit.   f. 

Chir.,  t.  xxvi,  p.  18,  1886. 
Guinard:    "Etiologie  et  Traitement,"  Rev.  Gen.  de  Chir.  et  de  Therap.,  Par  XII, 

p.  129,  1898. 
Henderson:     "Sphincter  in   Operations   for  Fistula   in   Ano,"    Mathews's   Med. 

Quart.,  vol.  iv,  p.  332,  1897. 
Mathews:    "Etiology  of  Fistula  in  Ano,"  Mathews's  Med.  Quart.,  vol.  ii,  p.  146, 

1895. 
Meisel:    Beitrage  zur  klinischen  Chiruryie,  Sept.,  1900. 
Meyer:    "Relation  of  Fistula  in  Ano  to  Pulmonary  Tuberculosis,"  etc.,  Mount 

Sinai  Hospital  Reports,  vol.  ii,  1901. 
Monroe:    "Treatment  of  Fistula  in  Ano,"  Med.  Summary,  Philadelphia,  Feb., 

1899. 
Pennington:    "Treatment  of  Fistula  in  Ano,"  Chicago  Med.  Record,  Dec,  1898. 
Polls:    "Traitement  des  Fistules  Anales,"  Scalpel,  Liege,  xlix,  p.  304,  1896. 
Quenu  et  Hartmann:    "Fistules  Ano-rectales,"  "Chir.  du  Rectum,"  P-  158,  1895. 
Saenger:    "Treatment  of  Recto-vaginal  Fistula,"  Trans.  Amer.  Assoc.  Obstet. 

and  Gynecol.,  vol.  iii,  p.  361,  1890. 
Sawyer:    "Treatment  of  Recto-vaginal  Fistula,"  Trans.  Amer.  Assoc.  Obstet.  and 

Gynecol.,  vol.  iii,  p.  259,  1890. 
Tuttle:    "Urethro-rectal  Fistula,"  Mathetvs's  Med.  Quart.,  vol.  v,  p.  104,  1898. 
"Treatment  of  Ano-rectal  Fistula,"  i\^.  Y.  Med.  Jour.,  Iviii,  p.  1,  1893. 
Wells:    "Phthisis  Complicating  Fistula  in  Ano,"  Mathews's  Med.  Quart.,  vol.  iv, 

283,  1897. 
Ziegler:    "Etiology  of  Fistula  in  Ano."  "Special  Path.  Anat."   (American  edi- 
tion), p.  663,  1898. 


CHAPTER  XX 

FECAL  INCONTINENCE 

Fecal  incontinence  is  the  involuntary  discharge  of  feces 
and  flatus,  and  is  dependent  upon  loss  of  control  over  the 
sphincter-muscles.  Incontinence  is  encountered  more  fre- 
quently in  women  than  in  men.  It  is  uncommon  in  children 
except  in  those  suffering  from  extensive  rectal  prolapse. 

There  are  two  forms  of  fecal  incontinence :  (a)  partial,  in 
which  well-formed  feces  are  normally  retained,  but  liquid  stools 
and  gas  are  involuntarily  discharged;  (b)  complete,  in  which 
neither  fecal  matter  nor  gas  can  be  retained. 

ETIOLOGY  AND   PATHOLOGY 

Incontinence,  partial  or  complete,  may  result  from  de- 
struction of  the  sphincter-muscles  by  operations  or  disease  in 
the  lower  rectum.  The  operation  which  is  most  frequently 
followed  by  incontinence  is  that  for  the  relief  of  fistula  in  ano. 
There  are  two  reasons  for  this :  first,  because  of  the  frequency 
of  fistula,  and,  second,  because  in  this  operation  division  of 
the  external  or  both  sphincters  in  one  or  more  places  is,  in 
the  majority  of  cases,  unavoidable.  Loss  of  sphincteric  power 
is  most  likely  to  follow  operations  in  which  the  incision  has 
been  carried  high  up,  dividing  the  internal  sphincter,  and  also 
in  cases  in  which  the  external  sphincter  is  severed  at  its  junc- 
tion with  the  sphincter  vaginae.  It  is  more  likely  to  follow 
when  the  muscles  have  been  cut  obliquely  (Fig.  76)  or  irreg- 
ularly than  when  they  are  cut  at  a  right  angle  (Fig.  75),  and 
its  frequency  is  increased  in  proportion  to  the  number  of  times 
the  muscles  are  cut;  but  the  author  has  frequently  cut  the 
muscle  two  or  more  times,  and  the  operation  was  not  followed 
by  incontinence  (Fig.  93).  Tubercular  patients  and  those  who 
are  generally  debilitated  are  sometimes  afflicted  with  incon- 
tinence after  operation,  because  the  wound  refuses  to  heal. 

Other  surgical  procedures  which  occasionally  cause  incon- 
tinence are  operations  for  hemorrhoids,  stricture,  fissure,  ulcer- 
ation, prolapse,  and  malignant  disease  where  it  is  necessary 
to  excise  the  rectum.  In  Whitehead's  operation  for  hem- 
(286) 


FECAL  INCONTINENCE  287 

orrhoids  this  accident  may  be  caused  by  stripping  off  the 
external  sphincter  during  operation,  or  by  involvement  of 
the  muscle  in  the  scar-tissue  resulting  from  failure  to  obtain 
primary  union. 

Incontinence  may  be  induced  by  injury  to  the  cord,  paral- 
ysis,'procidentia,  stricture,  pederasty,  rapid  divulsion  of  the 
sphincters  by  means  of  mechanic  dilators,  laceration  of  the 
muscles  during  labor,  and  by  other  conditions  or  diseases 
which  cause  frequent  straining  or  tearing  of  the  sphincter- 
muscles;  also  by  syphilitic,  tubercular,  chancroidal,  rodent,  or 
malignant  ulceration  at  the  anal  outlet. 

Slight  disease  or  a  trivial  operation  is  sometimes  followed 
by  incontinence;   but,  on  the  other  hand,  disease  or  operation 


Fig.  93. — Appearance  of  the  Anus  where  the  Sphincter  was  Cut  in  Three 
f'laces  in  a  Young  Woman  who  Recovered  Perfect  Control  of  the  Bowel 
in  Six  Weeks. 

may  be  extensive  and  the  patient  will  still  retain  perfect  con- 
trol of  the  bowel.  The  reason  for  this  has  not  yet  been  satis- 
factorily explained. 

Some  authorities  contend  that  incontinence  is  caused  by 
severing  the  nerves  during  the  operation;  but  the  author  is  not 
inclined  to  accept  this  view,  because,  in  most  rectal  operations, 
the  incisions  are  made  parallel  with  the  long  axis  of  the  bowel, 
and  do  not  extend  sufficiently  higii  to  cut  off  the  nerve-supply 
of  the  sphincter-muscle.  The  author  has  never  seen  incon- 
tinence follow  operations,  no  matter  how  extensive,  in  which 
the    wound    healed    by   primary   union.      He   believes    that   the 


288  .  DISEASES  OF  THE  RECTUM  AND  ANUS 

chief  cause  of  this  distressing  condition  is  imperfect  healing . 
of  the  wound  and  persistence  of  a  deep  sulcus  which  separates 
the  ends  of  the  muscles  and  permits  leakage  at  this  point.  He 
has  never  known  loss  of  control  of  the  sphincter  to  follow 
fistula  operations,  except  in  those  instances  in  which  such  a 
crevice  existed.  This  condition  is  easily  forestalled  by  pre- 
venting the  skin  from  encroaching  upon  the  wound  until  after 
the  latter  heals  up  level  with  the  surrounding  healthy  surface. 

In  exceptional  cases,  where  the  sphincter  has  not  been 
severed,  it  may  be  disabled  by  the  encroachment  of  cicatricial 
tissue,  binding  it  down  at  one  or  more  points. 

Kelsey  believes  the  explanation  of  fecal  incontinence  is 
vicious  cicatrization  which  prevents  the  ends  of  the  muscle 
being  brought  into  accurate  apposition.  If  this  is  so,  it  also 
explains  why  a  single  cut  may  cause  incontinence ;  the  ends 
of  the  sphincter  being  separated  for  some  distance  by  a  cic- 
atrix, there  is  no  fixed  point  of  support,  and  the  muscle  loses 
its  power.  In  another  case  the  muscle  may  be  divided  in  sev- 
eral places  and  heal  so  as  to  form  one  undivided  circle,  thus 
preventing  incontinence. 

Allingham  maintains  that  incontinence  is  due  to  (a)  the 
leaving  of  a  deep  sulcus;  (h)  weak  sphcing  of  the  sphincter, 
where  it  has  been  divided  in  two  places ;  and,  (c)  in  women,  to 
severing  the  vaginal  and  rectal  sphincters  at  the  point  of  their 
decussation. 

SYMPTOMS   AND   DIAGNOSIS 

The  chief  manifestation  complained  of  by  persons  sufifer- 
ing  from  fecal  incontinence  is  the  escape  of  gas  or  feces  at 
inopportune  times. 

The  frequency  with  which  this  takes  place  depends  prin- 
cipally upon  the  nature  of  the  incontinence  and  the  consistency 
of  the  stools.  In  partial  incontinence  there  is  only  a  slight 
leakage, — mucus,  gas,  and  Hquid  feces  escaping  involuntarily, 
— while  firm  and  well-formed  stools  are  evacuated  at  the  will 
of  the  patient.  When  incontinence  is  complete,  the  intestinal 
contents,  of  whatever  kind,  upon  reaching  the  lower  rectum 
are  discharged  without  warning  in  spite  of  all  efforts  to  retain 
them. 

There  is  no  class  of  sufferers  more  deserving  of  sympathy 
than  these  unfortunates  who,  for  obvious  reasons,  are  ostra- 


FECAL  INCONTINENCE  289 

cised  from  society  and  rendered  incapable  of  attending  to  their 
usual  duties.  The  escape  of  feces  makes  bathing  and  change 
of  clothing  at  short  intervals  and  at  the  most  inconvenient 
times  necessary. 

Patients  with  loss  of  sphincteric  power  who  have  chronic 
constipation  in  which  the  feces  collect  in  large  quantities  and 
remain  in  the  sigmoid  for  several  days  before  they  pass  into 
the  rectum  are  fortunate ;  on  the  other  hand,  those  suffering 
from  chronic  diarrhea  are  to  be  pitied.  Fright,  violent  exer- 
cise, and  extreme  heat,  by  increasing  peristalsis  and  the  fluidity 
of  the  stools,  also  contribute  to  the  discomfort  of  these  suf- 
ferers. 

The  ano-gluteal  region  is  constantly  moist,  excoriated,  and 
covered  with  feces.  In  recent  cases  in  which  the  sphincters 
have  been  destroyed  by  syphilis,  malignancy,  or  tuberculosis, 
there  are  deep  ulcers  at  the  muco-cutaneous  junction  which 
are  extremely  sensitive  and  cause  much  suffering  during  and 
after  stool.  In  cases  of  long  standing  there  is  a  deep  sulcus 
covered  by  scar-tissue  and  extending  upward  into  the  rec- 
tum; close  examination  will  show  that  leakage  occurs  at  this 
point.  This  is  because  the  ends  of  the  divided  muscle  are 
pulled  farther  apart  when  it  contracts.  Shortly  after  destruc- 
tion of  the  sphincter  there  is  usually  sufficient  time  between 
the  warning  given  by  the  approaching  stool  and  its  exit  for 
the  patient  to  reach  a  place  of  safety.  In  old  cases,  however, 
no  such  warning  sensation  is  experienced ;  on  the  contrary,  the 
anus  remains  patulous  and  offers  little  or  no  resistance  to  the 
feces,  or  to  the  finger  during  examination.  The  mucous  mem- 
brane also  is  frequently  prolapsed. 

PROGNOSIS 

Temporary  incontinence  occurs  frequently  after  fistula  op- 
eration, and  the  patient  is  unnecessarily  alarmed  because  of 
the  inability  to  retain  flatus  and  liquid  feces.  This  condition 
may  persist  until  the  sinus  is  completely  healed  and  the  ends 
of  the  sphincter  are  reunited. 

In  fecal  incontinence  the  prognosis  is  good  in  so  far  as 
life  is  concerned.  When  partial,  the  condition  can  always  be 
improved,  if  not  entirely  relieved ;  when  complete,  this  can  be 
accomplished  only  with  the  greatest  difficulty.  It  is  best  to 
inform  these  sufferers  that  more  than  one  operation  and  many 


290  DISEASES  OF  THE  RECTUM  AND  ANUS 

weeks  or  even  months  may  be  required  to  bring  about  the  desired 
result,  and,  furthermore,  that  there  is  httle  or  no  danger  from 
the  operation  except  that  attending  anestliesia. 

TREATMENT 

ReHef  or  cure  of  the  incontinence  should  not  be  attempted 
until  any  disease  in  the  rectum  causing  it  or  acting  as  a  source 
of  irritation  to  the  sphincters  has  been  corrected. 

Little  beyond  adding  to  the  comfort  of  the  patient  can 
be  accomplished  by  non-operative  treatment.  Everything  should 
be  done  to  render  the  stools  firm  or  semisolid  in  consistence  and 
vv^ell  formed,  thus  preventing  their  continuous  discharge.  In 
order  to  accomplish  this,  the  diet  must  be  regulated,  and  should 
consist  of  coarse  foods  known  to  exert  a  constipating  effect. 
Opiates,  astringent  and  other  remedies  should  be  administered 
to  overcome  peristalsis  and  arrest  secretion  so  that  the  feces 
may  accumulate  and  become  hardened.  Over  exercise  and 
excitement  must  be  avoided,  especially  during  the  summer 
months,  and  the  patient  should  rest  as  much  as  possible.  Cold 
drinks  in  large  quantities  must  be  interdicted.  The  parts 
should  be  cleansed  frequently  and  dusted  over  with  talcum  or 
other  soothing  powder  to  prevent  excoriation  and  the  intense 
pruritus  which  accompanies  it. 

Much  better  results  can  be  obtained  from  the  surgical 
treatment  of  incontinence,  and  an  operation  should  be  per- 
formed, if  the  patient  will  consent.  As  has  already  been  stated, 
the  patient  should  be  warned  of  the  serious  nature  of  his 
affliction,  and  that  considerable  time  and  more  than  one  opera- 
tion may  be  required  to  relieve  him.  A  complete  cure  cannot 
be  effected  in  every  case,  but  benefit  is  always  to  be  derived 
from  operative  procedures. 

The  most  practical  operations  suggested  for  the  relief  of 
incontinence  are  (a)  cauterisation  and  (b)  plastic  operation. 

Cauterization  is  best  suited  to  the  majority  of  cases.  This 
operation  is  similar  to  that  of  linear  cauterization  for  the  relief 
of  procidentia  recti.  The  flat  point  of  the  Paquelin  cautery, 
heated  to  a  dull  red,  is  pressed  through  the  mucous  membrane 
deeply  into  the  external  and  internal  sphincter-muscles,  and 
brought  out  at  the  muco-cutaneous  junction.  This  should  be 
repeated  as  many  times  as  is  necessary  and  at  equidistant 
points.     Strips  of  gauze  smeared  with  vaselin  should  be  kept 


FECAL  INCONTINENCE  291 

in  the  rectum  for  a  week  after  the  operation;  this  will  alleviate 
pain  and  prevent  adhesion  between  the  raw  surfaces. 

Immediately  after  the  operation  there  is  an  appreciable 
improvement  in  the  patient's  condition,  owing  to  stimulation 
of  the  dormant  sphincter-muscles;  the  full  benefit  of  this 
method  of  treatment,  however,  is  not  evident  until  scars  have 
formed  and  contracted  to  their  fullest  extent,  and  this  may 
require  weeks  or  months.  If  necessary,  the  operation  may  be 
repeated  at  intervals  of  several  months  until  the  incontinence 
is  entirely  overcome. 

Unless  the  operator  has  treated  many  cases  of  rectal  pro- 
lapse and  observed  the  shght  amount  of  contraction  following 
the  use  of  the  cautery  in  such  cases,  he  will  not  reaHze  the 
necessity  of  deep  and  thorough  cauterisation  in  order  to  secure 
a  stricture  sufficient  to  relieve  the  incontinence. 

Plastic  Operations  for  the  relief  of  this  condition  involve, 
in  most  instances,  the  same  principle  as  those  designed  for  the 
repair  of  a  lacerated  perineum.  Usually  this  operation  is  com- 
paratively simple,  and  consists  in  dividing  the  sphincter  at  a 
right  angle  where  the  muscle  is  weakest,  or  making  the  incision 
between  the  ends  of  the  muscle  at  the  point  of  leakage.  The 
offending  cicatricial  tissue  is  then  dissected  out.  A  careful 
search  is  made  for  the  ends  of  the  muscle,  and,  when  found, 
they  should  be  freshened,  made  as  symmetric  as  possible,  and 
brought  into  accurate  apposition  with  superficial  and  buried 
catgut  sutures,  and  a  dry  dressing  applied.  In  cases  where  the 
anus  is  patulous,  it  may  be  necessary  to  excise  a  section  of  the 
muscle  and  attached  structures  in  order  sufficiently  to  reduce 
the  size  of  the  aperture.  The  operation  should  be  varied  to 
suit  the  case.  When  the  old  wound  has  been  extensive,  scar- 
tissue  is  abundant,  and  the  incontinence  is  complete,  Lawson 
Tait's  flap-splitting  operation,  devised  for  the  repair  of  complete 
tears  of  the  recto-vaginal  septum  and  perineum,  should  be 
performed.  Allingham  has  modified  the  latter  operation  by 
turning  the  flaps  into  the  rectum  and  suturing  them  so  as  to 
narrow  the  anal  aperture. 

Some  surgeons  do  not  favor  either  of  the  operations  men- 
tioned, but  are  content  with  removing  the  cicatricial  tissue  and 
allowing  the  wound  to  heal  by  granulation.  Where  there  is 
complete  destruction  of  the  sphincter,  Willems  has  suggested 
freeing  the  end  of  the  rectum,  bringing  it  through  the  glutens 


292  DISEASES  OF  THE  RECTU.M  AND  ANUS 

maximus  muscle,  and  suturing  it  to  the  skin.  He  claims  to 
have  had  fair  success  with  this  method  of  treatment. 

Gersuny  has  been  successful  in  preventing  and  relieving 
incontinence,  especially  in  operations  of  rectal  excision,  by 
twisting  the  rectum  completely  around  and  thus  closing  it.  He 
claims  that  it  will  remain  closed,  but  that  elasticity  of  the  bowel 
allows  the  feces  to  escape  at  the  proper  time. 

Chetwood,  of  New  York,  successfully  operated  upon  one 
case  of  complete  incontinence  by  exposing  the  lower  end  of 
the  rectum  and  edges  of  the  glutei  and  then  proceeding  as 
follows :  "A  ribbon-shaped  piece  of  muscular  tissue,  about  one- 
fourth  of  an  inch  (0.65  centimeter)  in  breadth  and  one-six- 
teenth of  an  inch  (0.15  centimeter)  in  thickness,  are  now  dis- 
sected on  each  side  from  the  glutei  muscles,  having  an  attach- 
ment above.  These  two  muscular  ribbons  were  transposed,  so 
that  the  fibers  would  decussate  from  one  side  to  the  other; 
in  other  words,  the  right-hand  muscle  was  crossed  over  to 
the  left,  the  left  to  the  right,  underneath  the  ligamentous  con- 
nection between  the  anus  and  coccyx.  These  two  muscular 
strips  were  made  to  encircle  the  gut  and  to  meet  anteriorly, 
and  were  fastened  by  chromicized  catgut.  There  existed  a  very 
small  remnant  of  sphincter-muscle  on  each  side  of  the  rectum, 
and  to  that  the  new  muscular  strips  were  attached  by  additional 
sutures." 

The  author  has  been  accustomed  to  perform  left  inguinal 
colostomy  in  cases  of  fecal  incontinence  where  local  operations 
have  failed  and  the  patient  is  totally  incapacitated  for  business 
and  social  duties ;  also  in  those  cases  where  the  incontinence 
is  complicated  by  chronic  diarrhea  from  any  cause.  After  an 
artificial  anus  has  been  made,  if  the  patient  wears  a  properly- 
adjusted  bandage,  he  is  more  comfortable  by  far  than  in  his 
former  pitiable  condition. 

ILLUSTRATIVE  CASE 
Case  XI.  Incontinence  Due  to  Rupture  of  Sphincter-muscle. — A  few 
months  ago  Mrs.  B.  was  referred  to  me  to  be  treated  for  total  fecal  incon- 
tinence. She  gave  the  following  history:  Had  never  been  sick  a  day  until  two 
years  ago,  when  she  commenced  to  have  pains  in  the  region  of  the  tubes  and 
ovaries.  She  consulted  a  prominent  surgeon  of  Kansas  City,  Mo.,  who  removed 
these  organs.  After  she  had  recovered  from  the  immediate  effects  of  the  opera- 
tion, the  surgeon  informed  her  she  had  piles — which  was  news  to  her — and  that 
the  rectum  must  be  stretched.  Believing  this  essential,  she  consented,  was 
again  anesthetized,  and  the  operation  was  performed.    In  due  time  the  abdora- 


FECAL  INCONTINENCE  293 

inal  -Mound  healed  and  she  Avas  discharged.  She  had  no  control  of  the  bowels, 
and  the  feces  passed  out  as  quickly  as  they  entered  the  rectum.  This  was  very 
annoying  and  necessitated  the  constant  wearing  of  a  napkin.  The  surgeon  was 
consulted,  and  replied  that  the  muscle  would  regain  its  power  in  a  few  weeks. 
Such  did  not  occur,  however,  and,  as  weeks  and  months  rolled  by  and  no  im- 
provement was  noticeable,  she  insisted  on  something  being  done.  He  at  last 
endeavored  to  repair  the  injury  by  a  plastic  operation.  It  was  a  failure,  as 
were  two  subsequent  operations  performed  several  months  apart.  The  patient 
then  decided  to  try  some  one  else^  and  was  referred  to  me.  Examination  re^ 
vealed  the  presence  of  many  scars  in  the  anal  region  and  complete  loss  of 
sphincteric  power.  I  explained  to  her  what  I  thought  ought  to  be  done  and 
said  I  believed  she  could  be  benefited  and  possibly  cured,  if  she  would  place 
herself  absolutely  in  my  hands.  She  readily  consented,  and  two  days  later  I 
operated  at  All-Saints'  Hospital,  Kansas  City,  before  the  members  of  the  Uni- 
versity Medical  College,  post-graduate  class,  after  the  following  manner: — 

The  patient  was  placed  in  the  lithotomy  position,  with  the  limbs  well 
flexed  upon  the  abdomen.  A  large  bivalve  speculum  was  introduced  and  the 
rectum  irrigated,  after  which  it  was  wiped  perfectly  dry.  With  the  Paquelin 
cautery-point  a  number  of  deep,  linear  bur7is  were  made  into  the  rectal  wall, 
about  three-fourths  of  an  inch  (1.8  centimeters)  apart,  beginning  at  the  upper 
margin  of  the  internal  sphincter-muscle  and  terminating  in  the  skin  just  with- 
out the  external  sphincter.  Strips  of  iodoform  gauze  w^ere  smeared  with  vaselin 
and  placed  in  the  rectum  to  keep  the  rectal  walls  apart.  Three  days  afterward 
the  gauze  was  removed,  the  rectum  irrigated,  and  fresh  gauze  introduced. 
The  rectum  was  dressed  in  the  same  way  for  three  weeks,  when  the  patient 
was  discharged  from  the  hospital  able  to  retain  solid  feces.  She  was  informed 
that  the  contraction  would  be  more  marked  in  several  weeks,  but  that  it  was 
possible  another  operation  might  be  required.  I  saw  her  nine  months  after 
she  left  the  hospital,  and  she  could  retain  liquids  and  solids  without  difficulty. 
She  was  very  grateful  for  the  services  rendered  her.  This  case  has  been  re- 
ported at  length  because  it  shows  how  easily  incontinence  may  be  produced 
by  careless  divulsion,  and  also  because  it  is  desired  to  point  out  the  most 
satisfactory  way  of  relieving  this  distressing  condition. 


LITERATURE  ON  EECAL  INCONTINENCE 


Allingham:    "Diseases  of  the  Rectum  and  Anus,"  p.  6G,  1896. 

Dennis:    "System  of  Surgery,"  vol.  iv,  p.  492,  1896. 

Gant:    "Fecal  Incontinence,"  Internat.  Med.  Mag.,  vol.  x,  p.  2G8,  1901. 

Gerster:    Annals  of  Surgery,  xix,  p.  612,  1894. 

Gersuny:    Centrall)latt  fiir  Chirurgle,  vol.  xx,  p.  553,  1893. 

Goodsall  and  Miles:    "Diseases  of  the  Anus  and  Rectum,"  1900. 

Henderson:    "Sphincter  in  Fistula  Operations,"  Matlwws's  Med.  Quart.,  vol.  iv, 

p.  322,  1897. 
Kelsey:    "Surgery  of  the  Rectum  and  Pelvis,"  p.  117,  1897. 
Krause:    "Incontinence  of  Feces,"  Cincinnati  Lancet-Clinic,  June  17,  1899. 
Lisfranc:    Bulletin  de  la  Socicte  de  Chirurgie,  1861. 
Van  Buren :    "Fecal  Incontinence,"  "Diseases  of  the  Rectum  and  Anus,"  p.  191, 

1882. 
Willems:    Gentralhiatt  fiir  Chirvrgie,  No.   19,  1893. 


CHAPTER  XXI 

HISTORY,  ETIOLOGY,  PATHOLOGY,  SYMPTOMS,  DIAGNOSIS, 

AND    PROGNOSIS   OF   ANAL    FISSURE,   OR   PAINFUL 

ULCER  (IRRITABLE  ULCER,  SPHINCTERALQIA) 

An  anal  fissure  (from  the  Latin,  Ussura:  a  cleft,  slit,  or 
chap),  or  painful  ulcer,  is  a  superficial,  elongated,  slit-like  cleft 
situated  in  the  mucous  membrane  at  or  near  the  muco-cuta- 
neous  junction  (Plate  XVII),  and  is  characterized  by  acute, 
radiating  pain  and  paroxysmal  contraction  of  the  sphincter- 
muscle. 

HISTORY 

Painful  ulcer  or  fissure  has  been  written  about  and  dis- 
cussed since  the  time  of  the  ancients,  sometimes  under  one 
name  and  sometimes  under  another.  It  did  not  receive  the 
special  consideration  it  so  much  deserves  until  the  attention 
of  the  profession  was  drawn  to  it  by  the  most  excellent  con- 
tributions of  Boyer,  published  in  1818  and  1849.  This  author- 
ity had  a  vast  experience  in  the  treatment  of  the  disease  in  all 
its  forms.  Three  hundred  years  previous  to  this  time  the  cele- 
brated French  surgeon,  Ambroise  Pare,  made  valuable  con- 
tributions to  the  literature  of  anal  fissure.  Since  Boyer's  time 
Bodenhamer,  of  New  York,  through  his  most  excellent  work 
on  "Anal  Fissure,"  published  in  1868,  has  done  more  than  any 
other  writer  to  make  clear  the  importance,  frequency,  and 
proper  treatment  of  fissure. 

The  term  "fissure"  has  been  applied  to  every  form  of  pain- 
ful ulcer  within  the  grasp  of  the  sphincter-muscle,  but  it  does 
not  properly  describe  all  such  lesions,  because  many  of  them, 
beginning  as  elongated  and  slit-like  clefts,  become  enlarged, 
and  when  their  edges  are  separated  they  are  seen  to  be  circular 
or  irregular  in  shape.  Others  may  begin  in  the  latter  form  and 
produce  all  the  characteristic  symptoms  of  the  ordinary  fissures, 
but  should  not  be  classed  as  such.  For  this  reason  the  author 
in  deahng  with  this  subject,  will  employ  the  term  "painful 
ulcer"  to  describe  all  such  lesions,  irrespective  of  their  shape. 

Painful  ulcer  occurs  at  all  ages,  but  is  most  common  in 
adults.  It  is  more  common  in  infants  than  in  older  children. 
Writers  generally  maintain  that  it  is  met  with  more  frequently 
(294) 


2 

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CI 

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05 

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ANAL  FISSURE  295 

in  women  than  in  men.  It  has  been  the  author's  experience, 
however,  that  the  converse  is  true,  and  GoodsaU  is  of  the  same 
opinion,  having  treated  329  cases,  of  which  190  were  males  and 
139  were  females. 

Painful  ulcers  are  usually  single,  but  in  exceptional  cases 
there  may  be  two  or  more.  Out  of  221  cases  treated  by  Good- 
sail  in  St.  Mark's  Hospital,  London,  a  single  lesion  existed  in 
208 ;  in  12  there  were  two  fissures  and  in  1  only  three  were 
present. 

The  ulcers  vary  from  one-fourth  to  three-fourths  of  an 
inch  (63  millimeters  to  1.90  centimeters)  in  length  and  from 
one-sixteenth  to  one-half  inch  (15  millimeters  to  1.27  centi- 
meters) in  breadth,  and  are  narrowest  at  their  extremities. 
They  may  be  superficial  or  extend  entirely  through  the  mu- 
cosa, exposing  the  muscular  coat,  the  fibers  of  which  can  be 
seen  crossing  the  ulcer  at  a  right  angle.  They  are  parallel 
with  the  long  axis  of  the  bowel,  and  are  most  frequently 
located  posteriorly  at  or  near  the  median  line;  they  are  some- 
times situated  anteriorly  at  or  near  the  median  line,  and  in 
rare  cases  they  are  found  at  the  sides  of  the  anus. 

ETIOLOGY   AND   PATHOLOGY 

Of  the  many  causes  of  painful  ulcer,  the  most  common  Is 
constipation.  The  mucous  membrane  is  very  delicate,  and  may 
be  easily  lacerated  by  some  hard  substance  in  the  excreta  or 
torn  when  stretched  by  the  passage  of  a  large,  knotty  fecal 
mass  after  defecation  has  been  deferred  for  some  time.  More- 
over, the  glands  of  the  rectum  and  anus  may  fail  to  supply  the 
secretion  necessary  to  lubricate  the  parts  and  the  feces;  the 
mucous  membrane,  therefore,  becomes  dry,  inelastic,  and 
parchment-like,  and  is  rendered  more  liable  to  be  lacerated 
during  the  passage  of  the  dry  and  hardened  dejecta.  Again, 
when  allowed  to  collect  in  considerable  quantity,  the  feces  may 
obstruct  the  circulation  by  pressing  upon  the  blood-vessels,  and 
thus  cause  an  ulcer  by  necrosis ;  or  irritating  substances  in  the 
retained  feces  may  continually  abrade  the  mucosa,  exposing  it 
to  attack  by  pathogenic  bacteria  in  the  rectum,  resulting  event- 
ually in  an  ulcer. 

Painful  ulcer  may  be  due  to  congenital  narrowing  of  the 
anus,  atrophic  proctitis,  foreign  bodies  which  have  been  swal- 
lowed or  introduced  into  the  rectum  through  the  anus,  entero- 


296  DISEASES  OF  THE  RECTUM  AND  ANUS 

liths,  diseases  of  adjacent  organs,  stricture,  polyps,  procidentia 
recti,  diarrhea;  dysenteric,  syphilitic,  tubercular,  venereal,  or 
malignant  ulceration  of  the  rectum  or  colon ;  colitis,  or  by  other 
diseased  conditions  which  produce  rectal  discharge  or  pro- 
longed straining.  Again,  it  may  be  induced  by  pederasty,  rec- 
tal masturbation,  frequent  and  careless  introduction  of  the 
syringe-nozzle  when  giving  enemata,  pernicious  catharsis;  vio- 
lent and  hasty  stretching  of  the  mucosa  with  the  fingers,  specula 
or  mechanic  dilators,  by  direct  injury  or  operation  where  the 
wound  refuses  to  heal,  injury  by  the  child's  head  during  partu- 
rition; anterior  deviation  of  the  coccyx;  or  by  prurigo,  eczema, 
psoriasis,  herpes,  or  other  skin  disease  involving  the  anal  mar- 
gin. Hemorrhoids  are  said  to  be  a  frequent  cause  of  painful 
ulcer;  indeed,  Quenu  and  Hartmann  state  that  there  is  co- 
existence of  hemorrhoids  in  from  70  to  80  per  cent,  of  the  cases. 
While  the  writer  has  frequently  noted  the  simultaneous  occur- 
rence of  hemorrhoids  with  painful  ulcer,  he  does  not  believe 
that  they  cause  or  complicate  fissure  as  frequently  as  the  state- 
ments of  Quenu  and  Hartmann  imply.  The  highly-inflamed 
sentinel  pile,  which  sometimes  accompanies  a  painful  ulcer,  is 
secondary  to,  and  not  a  cause  of,  the  fissure.  The  author  agrees 
with  le  Dentu  and  Delbet,  who  are  of  the  opinion  that,  if  hem- 
orrhoids are  the  chief  cause  of  fissure,  simple  divulsion  or  in- 
cision of  the  sphincter  would  not  be  sufficient  to  relieve  the 
latter;  and,  again,  children,  in  whom  hemorrhoids  so  rarely 
occur,  would  not  suffer  from  painful  ulcers  as  frequently  as  is 
the  case. 

M.  Boyer  and  his  followers  believe  that  the  spasmodic 
contraction  of  the  sphincter-muscle  of  itself  constitutes  the 
disease,  and  that  the  fissure  or  rent  in  the  mucous  membrane 
is  secondary  to,  and  caused  by,  this  contraction.  The  author 
holds  that  the  reverse  is  the  true  state  of  affairs,  and  that  the 
painful  contraction  of  the  sphincter  is  secondary  to  an  irrita- 
tion arising  from  a  lesion  in  the  mucous  membrane  near  the 
anus.  He  is  fully  aware  of  the  fact  that  spasm  of  the  sphincter 
sometimes  occurs  when  the  mucous  membrane  is  perfectly 
sound,  but  he  believes  that  this  contraction  is  reflex,  and  caused 
by  disease  in  the  upper  rectum  or  neighboring  organs,  and 
rarely,  if  ever,  causes  painful  ulcer.  For  this  reason  he  does 
not  feel  justified  in  diagnosticating  fissure  in  ano  from  the  pres- 
ence simply  of  sphincteralgia. 


ANAL  FISSURE  297 

Ball  is  of  the  opinion  that  painful  ulcer  is  produced  by- 
tearing  the  semilunar  valves  (Fig.  94)  in  the  following  manner : 
"During  the  passage  of  a  motion  one  of  these  little  valves  is 
caught  by  some  projection  in  the  fecal  mass  and  its  lateral 
attachments  torn;  at  each  subsequent  motion  the  little  sore 
thus  made  is  reopened  and  possibly  extended ;  the  repeated  in- 
terference with  the  attempts  at  healing  ends  in  the  production 
of  an  ulcer,  and  the  torn-down  valve  becomes  swollen  and 
edematous,  constituting  the  so-called  pile,  or,  as  it  sometimes 
has  been  called,  the  'sentinel'  pile  of  the  fissure.  Most  of  us 
have  experienced  the  little  bits  of  skin  torn  down  at  the  sides 
of  the  finger-nails,  popularly  called  'torments,'  and  how  painful 
they  are  when  dragged  upon.  Now,  the  torn-down  anal  valve 
resembles  closely  this  condition  of  the  finger,  except  that  in 
the  former  it  is  situated  at  the  acutely  sensitive  anal  margin, 
and  subjected  to  the  periodic  strain  of  a  passing  motion;  it  is, 
therefore,  not  to  be  wondered  at  that  the  pain  should  be  so 
excessive  as  seriously  to  affect  the  general  health  and  render 
life  miserable." 

The  author  agrees  with  Ball  that  some  painful  ulcers  are 
produced  in  this  manner;  but  he  is  of  the  opinion  that  by  far 
the  greater  number  of  fissures  are  the  result  of  direct  injury  or 
tearing  of  any  part  of  the  mucosa,  and  not  necessarily  the  semi- 
lunar valves.  These  conclusions  are  based  on  the  examination 
of  a  large  number  of  hospital  and  private  patients,  in  the  ma- 
jority of  whom  there  were  no  so-called  "sentinel"  piles,  which 
would  have  been  present  if  the  semilunar  valves  had  been  torn 
down ;  in  other  cases  giving  no  previous  history  of  rectal  dis- 
ease an  injury  to  the  mucosa  by  hardened  feces  had  occurred, 
and  at  the  examination  made  a  few  hours  afterward  there  was 
observed  a  clean-cut,  incision-like  rent  (Plate  XVII)  at  the 
anus,  which  later  developed  sphincteralgia  and  the  usual  mani- 
festations of  fissure;  in  a  few  cases  the  fissure  unquestion- 
ably resulted  from  former  injury,  operation,  or  ulceration  at 
the  anal  outlet,  where  healing  was  delayed  by  neglect  or 
improper  treatment. 

The  macroscopic  appearance  of  a  painful  ulcer  and  adja- 
cent structures  depends  upon  its  cause,  size,  and  duration. 
When  due  to  an  injury, — e.g.,  the  passage  of  hardened  feces,^- 
if  seen  soon  after  the  accident,  the  edges  of  the  wound  are 
sharply  defined,  soft,  and  pHable,  and  not  swollen.     The  rent 


298  DISEASES  OF  THE  RECTUM  AND  ANUS 

may  be  superficial  or  so  deep  as  to  extend  through  the  mucosa 
and  submucosa  and  expose  the  muscle  below.  If  hemorrhage 
has  ceased,  the  wound  is  smeared  over  with  mucus  and  oozing 
serum.  The  mucous  membrane  is  normal  in  color,  and  at  this 
time  the  fissure  is  not  more  sensitive  than  any  other  superficial 
wound;  the  sphincter  is  not  contracted,  and  the  skin  about  the 
anus  is  moist  with  the  exudations,  but  not  inflamed.  When 
several  days  have  elapsed,  the  fissure  presents  a  decidedly  dif- 
ferent appearance.  Spontaneous  healing  of  such  a  wound 
rarely,  if  ever,  occurs,  because  it  is  torn  open,  exposed  to  in- 
fection, and  bruised  at  every  passage  of  feces;  little  particles 
of  fecal  matter  (fecoliths)  are  deposited  in  it,  and  the  nerves 
with  which  the  anal  canal  is  bountifully  supplied  are  constantly 
subjected  to  insult.  As  a  result  of  this  constant  irritation 
paroxysmal  or  tonic  contraction  of  the  sphincter-muscle  and 
coincident  pain  are  produced,  and  this  condition  of  things  con- 
stitutes the  typic  painful  ulcer,  or  fissure  in  ano.  The  ulcer  and 
surrounding  mucous  membrane  now  appear  highly  inflamed, 
and  are  extremely  sensitive.  The  edges  of  the  fissure  are 
swollen  and  edematous,  and  during  the  intervals  of  contraction 
are  separated,  but,  when  the  sphincter  contracts,  may  be  held 
in  apposition  or  overlap  each  other.  The  mucous  membrane 
and  skin  about  the  anus  are  constantly  bathed  with  an  acrid 
discharge  composed  of  mucus  and  some  pus,  which  causes 
excoriation  of  the  parts  and  intense  pruritus.  When  the  fissure 
is  due  to  tearing  and  extrusion  of  a  semilunar  valve  and  the 
wound  extends  beneath  the  skin,  the  latter  becomes  highly 
inflamed,  swollen,  edematous,  and  very  sensitive,  forming  the 
so-called  "sentinel  pile."    (Fig.  94.) 

When  a  painful  ulcer  has  existed  untreated  for  a  long  time, 
the  inflammation  may  subside  to  a  degree  and  the  parts  be- 
come less  sensitive ;  the  edges  of  the  ulcer  become  grayish  in 
color,  rounded,  and  indurated;  the  surrounding  mucous  mem- 
brane is  less  highly  colored,  but  is  chafed,  thickened,  inelastic, 
and  less  mobile.  The  sphincter-muscle  is  hypertrophied,  and, 
as  a  result  of  its  almost  constant  contraction,  the  anus  becomes 
small  and  may  resemble  the  infundibuliform  anus  of  the  passive 
pederast.  The  skin  of  the  ano-gluteal  region  is  excoriated  and 
the  anal  folds  are  thickened  and  parchment-like,  owing  to  the 
pruritus  and  constant  scratching  caused  by  the  discharge.  The 
"sentinel"  pile,  if  present,  is  smaller,  less  sensitive,  and  less 


ANAL  FISSURE 


299 


inflamed  than  formerly,  and  resembles  an  inflamed  cutaneous 
hemorrhoid.  In  exceptional  cases  vegetations  may  appear 
about  the  anus  as  a  result  of  the  constant  moistening  of  the 
buttocks. 

The  appearance  of  the  parts  in  painful  ulcer  secondary 
to  operation,  ulceration,  or  causes  other  than  injury  does  not 
differ  from  that  of  chronic  fissure  due  to  injury,  except  that 
it  may  be  longer,  broader,  or  deeper,  and  its  edges  are  more 
irregular;  there  is  no  "sentinel  pile,"  and  there  may  be  strict- 
ure above  the  fissure  or  a  tight  constriction  of  the  skin  below 
it,  produced  by  a  cicatrix. 


Fig.  94.— Showing  Fissure  Caused  by  the  Tearing  and  Dragging  Downward  of 
the  Semilunar  Valves  and  the  Formation  of  the  Typic  "Sentinel  Pile." 
To  the  Left,  Above,  are  Shown  the  Semilunar  Valves;  on  the  Extreme 
Right,  a  Little  Lower  Down,  is  Shown  a  Torn  Valve;  while  in  the  Center 
is  the  Fissure  Leading  to  the  "Sentinel,"  or  External  Pile,  at  the  Anal 
Margin. 

The  edges  of  any  fissure  may  become  undermined  and 
allow  foreign  bodies,  fecoliths,  and  pyogenic  bacteria  to  lodge 
beneath  them,  causing  submucous  or  marginal  abscess,  which 
usually  results  in  blind  internal,  complete  internal,  or  complete 
fistula. 

In  discussing  the  pathology  of  painful  ulcer  the  writer  has 
intentionally  omitted  to  mention  the  superficial  ulcerations  and 
fissures  of  the  mucosa  occurring  above  the  sphincter,  for  the 
reason  that  they  are  not  accompanied  by  sphincteralgia,  which 
characterizes  true  painful  ulcer. 


300  DISEASES  OF  THE  RECTUM  AND  ANUS 

SYMPTOMS 

In  proportion  to  the  size  of  the  lesion,  painful  ulcer  (fis- 
sure) causes  more  suffering,  reflex  manifestations,  and  worry 
than  any  other  ano-rectal  disease.  The  author  has  seen  a  large 
number  of  men,  otherwise  stout  and  healthy,  who  were  entirely 
incapacitated  for  business  or  other  duties  by  a  slight,  rent  in  the 
mucous  membrane,  not  more  than  half  a  line  in  depth  and  less 
than  one-half  inch  (1.27  centimeters)  in  length. 

From  a  clinic  stand-point  painful  ulcer,  or  fissure  in  ano, 
may  be  divided  into  two  stages :  the  first  stage  begins  at  the 
time  the  rent  in  the  mucous  membrane  is  made,  and  ends  with 
the  inauguration  of  the  second  stage,  sphincteralgia,  which  is  the 
pathognomonic  symptom  of  this  disease.  The  manifestations 
of  painful  ulcer  are  in  most  cases  well  defined,  and  are  as  fol- 
lows : — 

1.  Pain  and  sphincteralgia.  7.  Reflex  disturbances. 

2.  Constipation.  8.  Proctitis. 

3.  Flatulence.  9.  Change  in  the  character 

4.  Hemorrhage.  of  the  feces. 

5.  Discharges.  10.  Melancholia  and  nerv- 

6.  Pruritus.  ousness. 

The  Pain  caused  by  a  fissure  at  its  inception  is  not  severe. 
When  the  rent  occurs  the  patient  has  an  acute  smarting,  tear- 
ing sensation  at  the  anus,  which  is  of  short  duration,  but  re- 
turns at  each  subsequent  stool ;  in  the  intervals  there  is  no 
decided  pain,  but  slight  sensations  of  heat  and  drawing  about 
the  anus  are  complained  of  by  the  patient.  In  the  second 
stage,  when  paroxysmal  contractions  of  the  sphincter  have  begun, 
the  suffering  is  exceedingly  intense  during  and  for  some  time 
after  defecation.  The  pain  caused  by  the  passage  of  the  feces 
is  of  a  severe  tearing,  burning  character,  confined  to  the  lower 
rectum,  and  of  comparatively  short  duration.  It  may  be  ag- 
gravated by  spasms  of  the  sphincter,  but  true  sphincteralgia  does 
not  begin  until  some  time  after  defecation. 

Many  proctologists  have  unsatisfactorily  attempted  to  ex- 
plain the  decided  lapse  of  time  between  the  act  of  defecation 
and  the  beginning  of  sphincteralgia.  Boyer  maintained  that  the 
sphincteralgia  was  of  itself  an  idiopathic  disease,  and  that  the 
rent  in  the  mucosa  was  secondary  to  and  caused  by  the  con- 
tractions of  the  sphincter:  a  view  not  held  by  modern  writers. 


ANAL  FISSURE  301 

The  pain  from  sphincteralgia  is  dull  and  agonizing  in  character, 
and  is  felt  in  its  greatest  severity  in  the  sacro-coccygeal  region. 
It  is  so  severe  that  the  patient  easily  acquires  and  quickly  be- 
comes a  slave  to  the  habit  of  using  drugs  just  previous  to 
going  to  stool  to  obviate  the  excruciating  after-pain. 

Constipation  is  always  a  prominent  symptom  of  painful 
ulcer,  and  very  naturally  so,  because  of  the  tendency  of  the 
patient  to  defer  defecation,  and  thus  escape  as  long  as  possible 
the  pain  attending  an  action. 

Flatulence  is  present  to  a  greater  or  less  extent  in  nearly 
all  cases  of  painful  ulcer,  and  is  most  evident  after  an  action 
has  been  deferred  for  several  days.  Bodenhamer  says  he  has 
never  seen  a  case  of  fissure  in  ano  in  which  there  was  not  more 
or  less  flatulence. 

Hemorrhage  may  be  a  symptom  of  painful  ulcer,  and  may 
occur  at  any  stage  of  the  disease ;  in  most  cases  it  is  unimpor- 
tant. It  may  be  slight  or  profuse  and  seen  in  streaks  upon 
the  feces,  or  the  blood  may  trickle  down  the  patient's  legs  for 
a  considerable  time  after  defecation;  sometimes  the  hemor- 
rhage continues  until  the  patient  becomes  faint  from  loss  of 
blood. 

The  Discharges  from  a  painful  ulcer  may  be  scant  or  abun- 
dant, depending  upon  its  size  and  the  amount  of  irritation  pro- 
duced by  it.  In  most  cases  the  discharge  is  slight,  and  is  notice- 
able only  by  the  moisture  about  the  anus.  It  is  composed 
principally  of  mucus  and  a  small  amount  of  pus.  In  exceptional 
cases  a  fistula  may  have  an  outlet  through  a  fissure;  the  dis- 
charge then  contains  more  or  less  thick,  yellozv  pus.  In  those 
cases  in  which  the  edges  of  the  ulcer  and  the  surrounding  mu- 
cous membrane  are  acutely  inflamed  and  in  which  the  discharge 
is  retained  and  allowed  to  decompose,  a  proctitis  may  ensue; 
tenesmus  will  then  be  present,  accompanied  by  an  abundant 
discharge  of  mucus. 

Pruritus  is  one  of  the  most  persistent  and  annoying  symp- 
toms of  painful  ulcer.  The  author  has  been  told  by  patients 
that  the  itching  was  more  difficult  to  bear  than  the  sphinc- 
teralgia, and  that  if  relief  was  not  obtainable  they  would  com- 
mit suicide,  because  rest  was  impossible.  The  pruritus  is  usu- 
ally induced  by  the  acrid  discharge  from  the  ulcer  which  col- 
lects, between  the  rugse,  wdiere  it  decomposes  and  produces 
a  chafed  condition  of  the  skin  of  the  ano-gluteal  region.    The 


302  DISEASES  OF  THE  KECTUM  AND  ANUS 

intensity  of  the  itching  depends  largely  upon  the  extent  of 
the  excoriations,  and  is  worse  in  fleshy  persons,  whose  but- 
tocks remain  in  contact.  In  rare  instances  excessive  itching 
is  present,  although  the  skin  is  perfectly  sound.  In  such  cases 
the  pruritus  is  reflex,  and  is  the  result  of  the  lodgment  of  a 
minute  fecolith  or  small  foreign  body  beneath  the  undermined 
edges  of  the  ulcer. 

Reflex  Disturbances  in  neighboring  organs  or  distant  parts 
of  the  body  frequently  accompany  this  disease.  It  is  not  un- 
usual for  these  patients  to  complain  of  pain  in  the  region  of  the 
uterus,  tubes,  ovaries,  bladder,  prostate,  urethra,  or  testicles,  or 
even  in  the  heel,  which  is  considered  by  some  as  one  of  the  most 
constant  symptoms  of  this  disease.  Again,  the  pain  may  be 
reflected  up  the  back,  to  the  hips,  and  down  the  leg,  and  is 
frequently  mistaken  for  sciatica.  Perhaps  the  most  common 
reflex  disturbance  set  up  by  fissure  in  ano  is  that  present  in 
the  bladder  and  urethra,  inducing  frequent  desire  to  urinate, 
difficult  micturition,  and  sometimes  complete  retention  of 
urine:  a  condition  which  is  largely  due  to  the  irritable  condi- 
tion of  the  sphincter  and  levator  ani  muscles.  Because  of  the 
great  pain  attending  defecation,  sufferers  from  painful  ulcer 
frequently  postpone  defecation  for  several  days,  and  when  stool 
does  occur  the  feces  are  discharged  in  the  form  of  small  round 
balls  or  of  large  scybalous  masses.  Again,  when  the  stools  are 
evacuated  regularly,  the  feces  are  string  or  tape-like  in  some 
cases,  or  they  appear  as  short  pieces  in  others,  in  which  the 
pain  causes  spasm  of  the  muscle  and  involuntary  closure  of 
the  anus,  which  actions  sever  that  portion  of  the  feces  external 
to  the  anus. 

Melancholia  and  Nervousness  are  ordinarily  factors  in  painful 
ulcer.  This  is  probably  largely  due  to  the  great  pain  accom- 
panying this  disease,  which  leads  the  patient  to  believe  that 
he  is  afflicted  with  cancer,  and  is  incurable.  The  anguish  and 
depression  experienced  by  some  of  the  sufferers  are  pitiable, 
and  not  a  few  of  them  manifest  suicidal  tendencies ;  their  feat- 
ures are  pinched,  indicating  suffering,  and  some  of  them  be- 
come physic  and  mental  wrecks. 

The  so-called  "sentinel  pile"  is  not  always  present,  but 
when  it  is  a  complication  of  painful  ulcer  it  causes  sensations 
of  heat  and  fullness  about  the  anus  and  considerable  acute 
pain  when  irritated  by  exercise. 


ANAL  FISSURE  303 

Because  of  the  constantly  moist  condition  of  the  parts, 
vegetations  are  sometimes  a  compHcation  of  fissure  in  ano,  and, 
as  in  other  parts,  they  are  characterized  by  an  offensive  odor. 

Painful  ulcers  in  syphilitic  subjects  are  usually  multiple.  In 
such  cases  the  inguinal  and  femoral  glands  may  become  in- 
filtrated, but  cause  httle  pain. 

DIAGNOSIS 

The  diagnosis  of  painful  ulcer,  or  fissure  in  ano,  when  un- 
complicated, is  not  difficult,  because  its  symptoms  are  charac- 
teristic, usually  well  defined,  and  the  lesion  is  at  the  verge  of  the 
anus,  where  it  can  be  exposed  easily  and  thoroughly  examined. 
When  an  ulcer  located  at  or  near  the  muco-cutaneous  junc- 
tion is  elongated,  has  sharply-defined  edges,  and  is  extremely 
sensitive,  and  when  the  patient  gives  a  history  of  having 
experienced  tearing,  burning  pains  during  defecation,  followed 
shortly  afterward  by  dull,  heavy,  agonizing  pains  over  the 
sacro-coccygeal  region,  a  diagnosis  of  painful  ulcer  is  justi- 
fiable. In  order  to  avoid  error  in  diagnosis  in  these  cases,  a 
systematic  examination  should  be  made.  After  the  rectum  has 
been  emptied  and  the  anus  cleansed  the  patient  should  be 
placed  on  the  left  side,  in  the  lithotomy  position,  or  other 
posture  in  which  a  good  view  of  the  parts  may  be  had;  the 
nates  should  be  separated  and  the  region  around  the  anus 
thoroughly  inspected  for  acutely  inflamed  external  piles  ("sen- 
tinel piles"),  or  for  excoriations,  moisture,  vegetations,  or  other 
evidences  of  discharge  from  painful  ulcer;  attention  should  be 
directed  to  the  appearance  of  the  anus,  which  in  fissure  is  al- 
ways tight  and  drawn  inward,  resembling  the  funnel-shaped 
anus  of  the  sodomist.  By  pressing  the  anus  inward  suddenly, 
if  a  fissure  is  present  the  sphincter  will  spasmodically  contract 
and  the  patient  cry  out  because  of  the  pain  ehcited  by  pressure 
upon  the  ulcer.  The  anal  outlet  should  now  be  exposed  by 
placing  a  thumb  on  either  side  of  the  anus  and  everting  it. 
This  will,  in  most  instances,  reveal  the  location  of  the  ulcer, 
which  is  usually  posteriorly,  in  or  near  the  median  line;  in 
exceptional  cases,  where  the  folds  of  the  mucosa  are  abundant 
and  the  fissure  is  small,  the  latter  may  be  hidden  between  the 
folds,  and  is  found  with  difficulty. 

Where  the  sphincter-muscle  is  hypertrophied  and  tightly 
contracted,  preventing  eversion  of  the  anus,  the  probe,  finger, 


304  DISEASES  OF  THE  RECTUM  AND  ANUS 

or  speculum  must  be  used  to  locate  the  ulcer.  The  probe, 
thoroughly  lubricated,  should  be  introduced  well  into  the  rec- 
tum, and  pressure  made  at  every  point  until  the  fissure  is 
found;  contact  of  the  probe  with  the  ulcer  will  be  indicated 
by  spasm  of  the  sphincter  and  sharp  pain.  Digital  examina- 
tion should  always  be  made  when  a  fissure  is  suspected.  The 
well-oiled  finger  should  be  introduced  slowly  and  gently,  and 
the  condition  of  the  anal  outlet  carefully  noted;  if  a  painful 
ulcer  exists,  the  sphincter-muscle  is  rigid,  resists  the  introduc- 
tion of  the  finger,  and  tightly  contracts  around  it ;  the  mucous 
membrane  is  swollen;  the  finger  easily  detects  the  slit-like  de- 
pression and  indurated  edges  of  the  ulcer,  which  when  touched 
gives  rise  to  pain  and  sphincteric  contraction.  A  speculum 
should  never  be  employed  until  all  other  means  of  locating  the 
lesion  have  failed;  if  used,  one  which  is  small  and  as  nearly 
the  shape  of  the  index  finger  as  possible  should  be  selected 
(Fig.  13) ;  it  should  be  inserted  cautiously,  opened  gently,  and 
the  field  in  front  of  it  examined;  it  should  then  be  withdrawn 
and  reintroduced  as  often  as  is  necessary  to  inspect  the  mucosa 
until  the  ulcer  is  found.  Under  no  circumstances  should  a 
speculum  be  turned  on  its  axis  while  in  the  rectum. 

Except  in  children,  where  they  may  be  caused  by  congen- 
ital narrowing  of  the  anus,  multiple  fissures  are  usually  of  ve- 
nereal origin;  consequently,  careful  examination  of  other  parts 
of  the  body  should  be  made  for  evidences  of  syphilis.  The 
writer  has  lately  treated  two  children,  less  than  three  years  of 
age,  for  multiple  painful  ulcers  due  to  congenital  syphiHs ;  also 
two  men  in  whom  the  fissures  were  caused  by  syphihtic  con- 
dylomata ;  in  another  case  the  lesions  were  due  to  chancroidal 
ulceration,  and  in  still  another  case  the  ulcers  were  secondary 
to  gonorrheal  infection.  Again,  multiple  fissures  are  some- 
times caused  by  atrophic  proctitis,  in  which  affection  they  are 
a  most  annoying  complication. 

Although  painful  ulcer  is  so  plainly  manifest  by  its  symp- 
toms and  appearance,  it  is  nevertheless  often  confused  with 
other  affections.     It  is  most  frequently  mistaken  for:^ 

1.  Ulceration.  3.  Neuralgia  of  the  anus  and 

2.  Spasmodic  contraction  of  sacro-coccygeal  region. 

the  sphincter  from  other     4.  Hemorrhoids, 
causes.  5.   Blind  internal  fistula. 

6.    Diseases  of  neighboring  organs. 


ANAL  FISSUKE 


305 


Ulceration  about  the  anus  due  to  a  chancre  is  characterized 
by  its  cup  shape,  its  indurated  edges,  and  the  absence  of  pain  or 
sphincteralgia.  Chancroidal  ulcers  can  be  differentiated  from 
fissure  by  their  number,  larger  size,  circular  or  irregular  form, 
superficial  nature,  and  tendency  to  involve  both  the  mucous 
membrane  and  skin.  The  principal  points  of  difference  be- 
tween fissure  in  ano  and  ordinary  rectal  ulceration  are : — 

Table  X.    Differential  Diagnosis  of  Fissure  and  Ulceration 


PAINFUL   ulcer    (FISSURE 
IN  ANO) 


Occurrence. 

In    middle-aged   robust    per- 

sons and  infants. 

Onset. 

Suddenly,  after  hard  stool. 

Location. 

Posteriorly  at  muco-cutane- 

ous  junction. 

Pain. 

Intense. 

Character  of 

Sharp    and    tearing    during 

pain. 

defecation;    dull  and  ach- 

ing   when     sphincteralgia 

begins. 

Location  of 

Anus    during   stool;     sacro- 

pain. 

coccygeal  region  later. 

Sphincter. 

Tonically   contracted. 

Shape  of  lesion. 

Long,  narrow,  and  slit-like. 

Sensitiveness. 

Very  sensitive. 

Hemorrhage. 

May  occur;    slight. 

Stools. 

Constipated  and  hardened. 

Defecation. 

Painful. 

Discharges. 

Feces  streaked  with  blood. 

Edges  of  lesion. 

Sharply  defined. 

Duration. 

Usually  short  when  properly 

treated. 

Prognosis. 


Good  when  uncomplicated. 


ULCERATION 

In  debilitated  adults,  rarely 
in  children. 

Gradual. 

Except  when  venereal,  any- 
where above  the  sphincter. 

Slight. 

Heavy  and  burning;  most 
noticeable  during  inter- 
vals of  defecation. 

In  the  rectum  at  any  point. 

Normal  or  patulous. 

Round  or  irregular. 

Slightly  sensitive. 

Frequent  and  profuse. 

Regular,  or  frequent  and 
liquid. 

Slightly  painful. 

Blood,  mucus,  and  pus. 

Ragged  or  rounded. 

Short  when  traumatic ;  pro- 
longed when  syphilitic, 
tubercular,   or  malignant. 

Good  when  simple;  grave 
when  tubercular,  syphi- 
litic, or  malignant. 


Spasmodic  Sphincteric  Contraction  from  other  causes  is  fre- 
quently mistaken  for  painful  ulcer.  The  author  has  had  many 
cases  referred  to  him  which  had  been  diagnosticated  as  fissure 
because  of  tight  contraction  of  the  sphincter  and  in  which  upon 
examination  no  rent  in  the  mucosa  could  be  found.  The  irri- 
tation to  the  sphincter  in  these  cases  was  due  to  disease  higher 
up  the  bowel,  foreign  body  in  the  rectum,  fecal  impaction,  skin 
eruption  about  the  anus,  or  disease  or  injury  of  the  coccyx. 


306  DISEASES  OF  THE  RECTUM  AND  ANUS 

Neuralgia  of  the  Rectum  may  be  mistaken  for  fissure,  owing 
to  the  excruciating  character  of  the  neuralgic  pain.  A  close 
study  of  the  case  will  clear  up  the  diagnosis,  because  the  pain 
is  not  confined  to  the  sacro-coccygeal  region,  but  may  invade 
any  part  of  the  rectum.  It  is  not  always  accompanied  by  spasm 
of  the  sphincter,  and  examination  fails  to  reveal  any  break  in 
the  mucosa  or  excoriation  of  the  skin  about  the  anus. 

Hemorrhoids,  when  external  and  inflamed  or  internal  and 
ulcerated  or  strangulated,  may  be  confused  with  fissure  by 
physicians  who  neglect  to  make  a  thorough  examination. 
Otherwise  there  is  no  reason  why  hemorrhoidal  tumors  should 
be  mistaken  for  fissure. 

Blind  Internal  Fistula,  especially  when  its  opening  is  near 
the  anus,  is  frequently  mistaken  for  fissure,  because  of  pain 
produced  during  defecation,  irritation  of  the  sphincter-muscle, 
inflamed  condition  of  the  surrounding  mucosa,  and  the  ex- 
coriations caused  by  the  discharge.  A  close  examination  of 
the  latter  shows  it  to  be  thick,  yellow  pus,  and  not  mucus 
mixed  with  but  a  slight  amount  of  pus  as  in  fissure ;  careful 
probing  will  reveal  the  presence  of  the  sinus.  It  is  well  to 
remember  that  a  fissure  may  be  the  point  of-  exit  of  this  variety 
of  fistula. 

Diseases  of  Neighboring  Organs — uterus,  tubes,  ovaries,  va- 
gina, bladder,  urethra,  seminal  vesicles,  and  prostate — may 
cause  reflected  pain  in  the  lower  rectum  and  sometimes  spasm 
of  the  sphincter,  simulating  the  same  conditions  induced  by 
painful  ulcer. 

PROGNOSIS 

The  prognosis  of  uncomplicated  painful  ulcer,  or  fissure 
in  ano,  is  good.  In  a  general  way,  it  may  be  said  that  intel- 
Hgent  treatment  is  in  nearly  every  case  followed  by  gratifying 
results;  when,  however,  the  disease  is  complicated  by  ulcera- 
tion, hemorrhoids,  polyps,  or  blind  internal  fistula,  or  when 
improperly  treated  or  left  to  heal  spontaneously,  it  may  be 
prolonged  indefinitely,  causing  much  pain  and  reflex  disturb- 
ances, incapacitating  the  patient  for  his  daily  duties,  and  finally 
making  a  complete  nervous  wreck  of  him.  Fissure  in  ano  is 
one  of  the  few  rectal  diseases  which  respond  to  palliative  treat- 
ment in  a  majority  of  cases;  if  these  measures  should  fail,  a 
cure  can  speedily  be  effected  by  operative  procedures. 


CHAPTER  XXII 

TREATMENT  OF  ANAL  FISSURE,  OR    PAINFUL  ULCER 

Patients  suffering-  from  painful  ulcer  frequently  defer 
consulting  a  physician  as  long  as  possible,  some  because  they 
hope  to  recover  without  medical  aid  and  others  because  they 
dread  the  examination.  As  spontaneous  cure  very  rarely  takes 
place,  the  old  saying — "a  stitch  in  time  saves  nine" — is,  indeed, 
applicable  in  these  cases,  for,  when  the  physician's  attention  is 
called  to  a  fissure  in  its  incipiency,  he  can  effect  a  speedy  cure 
by  correcting  certain  errors  in  habits  and  diet,  together  with 
cleanliness  and  topic  applications. 

The  treatment  of  painful  ulcer  is: — ■ 

1.   Non-operative.  2.   Operative. 

N0N=OPERATIVE   TREATMENT 

Non-Operative  treatment  is  efficient  in  many  cases.  The 
principles  which  should  guide  in  non-operative  treatment  are 
several,  and  in  the  order  of  their  importance  are  as  follows: — 

1.  Correction,  if  possible,  of  any  complications. 

2.  Attention  to  cleanliness  and  prophylaxis. 

3.  Regulation  of  the  stools. 

4.  Regulation  of  the  diet. 

5.  Rest  in  the  recumbent  position. 

6.  Prevention  and  relief  of  pain  and  sphincteralgia. 

7.  Stimulation  or  cauterization  of  the  wound. 

8.  Administration  of  tonics  or  constitutional  remedies  if 
necessary. 

If  possible,  any  complications — such  as  hemorrhoids,  polyps, 
ulceration  of  whatever  kind,  affections  of  neighboring  organs, 
or  other  disease  which  may  aggravate  the  fissure — should  be 
corrected. 

By  attention  to  cleanliness  and  prophylaxis  much  can  be 
done  to  render  the  patient  comfortable,  put  the  wound  in  a 
healthy  state,  and  prevent  a  recurrence  of  the  disease.  The 
parts  should  be  washed  morning  and  night  and  after  each  stool 
with  sterile  water,  or  weak  solutions  of  carbolic  acid,  corrosive 

(307) 


308  DISEASES  OF  THE  RECTUM  AND  ANUS 

sublimate,  silver  citrate  or  lactate,  or  other  reliable  antiseptic. 
Every  other  day  the  edges  of  the  fissure  should  be  separated 
and  all  portions  of  it  thoroughly  cleansed.  Prophylactic  meas- 
ures consist  in  the  substitution  of  cotton  or  soft  sponges  for 
rough  toilet  paper,  and,  in  children,  in  the  correction  of  the 
acidity  of  the  stools. 

Regulation  of  the  Stools  is  most  important,  and  every  effort 
should  be  made  to  bring  about  one  semisolid  action  daily; 
liquid  and  large  and  knotty  stools  are  equally  undesirable. 
Drastic  purgatives  should  never  be  administered  in  these  cases. 
To  regulate  the  number  and  consistency  of  the  stools,  the  fol- 
lowing remedies  have  proved  efficient  in  the  author's  practice : 
Castor-oil,  ohve-oil,  Carabafia  water,  compound  licorice- 
powder,  salts,  and — in  children — the  fluid  extract  of  cascara 
sagrada  and  syrup  of  figs.  In  patients  who  have  been  neg- 
lected and  in  those  in  whom  it  is  impossible  to  regulate  the 
stools,  and  the  feces  accumulate  and  become  firm,  relief  is  to 
be  had  only  from  enemas.  In  some  cases  a  simple  injection  of 
soap-suds  will  be  sufficient ;  in  others  it  may  be  necessary  to 
add  olive-oil  or  glycerin  to  the  enema  or  to  inject  several  pints 
of  an  infusion  of  flaxseed  into  the  bowel  before  the  fecal  mass 
is  sufficiently  softened  and  lubricated  to  be  discharged  without 
lacerating  the  parts  and  causing  much  pain  and  sphincteralgia. 
In  giving  enemas  much  care  should  be  observed  to  select  a 
syringe  with  a  smooth  nozzle ;  the  latter  should  be  anointed 
with  some  stiff  lubricant  and  introduced  slowly  into  the  bowel 
by  pressing  it  against  the  rectal  wall  opposite  the  ulcer.  In 
order  to  reduce  pain  to  a  minimum,  the  writer  attaches  a  very 
large,  soft-rubber  male  catheter  to  the  syringe.  This  can  be 
introduced  with  ease,  and  does  not  irritate  the  parts. 

Regulation  of  the  Diet  is  an  essential  feature  of  the  treat- 
ment of  fissure,  and  foods  known  to  have  a  constipating  effect 
should  be  prohibited.  The  patient  should  be  required  to  live 
upon  fruits,  milk,  soups,  eggs,  and  other  liquid  and  semisolid 
foods;  ingestion  of  large  quantities  of  water  is  advisable,  in 
order  to  soften  the  feces  as  much  as  possible. 

Quiet  and  Rest  in  the  recumbent  position  must  be  insisted 
upon,  and  active  exercise — such  as  walking,  horseback-riding, 
cycling,  etc. — prohibited,  since  the  musculature  of  the  perianal 
region  is  thereby  excited  to  such  a  degree  as  to  keep  the  fissure 
in  a  state  of  constant  irritation  and  prevent  healing. 


TREiiTMENT  OF  ANAL  FISSURE  399 

In  the  Prevention  and  Relief  of  Pain  and  Sphincteralgia,  in 

addition  to  regulating  and  softening  tlie  feces,  much  can  be 
accomplished  by  the  intelligent  employment  of  simple  reme- 
dies. In  cases  where  the  ulcer  is  extremely  irritable  much  suf- 
fering can  be  obviated  by  applying  some  soothing  ointment  or 
lotion  just  before  defecation,  or  by  placing  a  pledget  of  cotton 
saturated  with  cocaine  or  eucaine  in  the  ulcer  and  allowing  it 
to  remain  for  a  short  time  before  stool. 

For  rehef  of  the  pain  caused  by  defecation  Cripps  recom- 
mends the  following  ointment : — 

ij  Ext.  conii    3ij  81 

Olei  ricini 3iij  121 

Ungt.  lanolini    q.  s.  ad  gij  601 

Misce. 

For  the  same  purpose  Adler  advises  a  suppository  con- 
sisting of : — 

IJ  Ext.  belladonnse    gr.  V2  03 

Ext.  opii  aq m  V3  02 

01.  theobromse   ?hx  65 

irisce  et  fiat  suppositoria  j. 

Malgaigne  suggests  that  laceration  of  the  ulcer  by  passage 
of  feces  and  the.  pain  incident  thereto  can  sometimes  be  pre- 
vented by  squeezing  and  supporting  the  ulcer  between  the 
thumb  and  index  finger  during  defecation. 

Heat  in  any  form  can  always  be  relied  upon  for  reducing 
the  pain  and  irritability  of  the  sphincter-muscle.  In  these  cases 
nothing  is  more  soothing  to  the  anus  than  the  application,  for 
a  few  minutes  after  defecation,  of  cotton  wrung  out  of  water 
as  hot  as  can  be  borne.  Constant  irrigation  with  warm  water 
through  a  return-flow  tube  serves  the  same  purpose  ;  it  is  not  so 
reHable,  however,  and  considerable  irritation  is  induced  by  the 
tube.  The  injection  and  retention  of  1  or  2  ounces  (30  to  60 
cubic  centimeters)  of  warm  olive-oil  in  the  rectum  when  pain 
is  intense  will  nearly  always  quiet  the  sphincter.  This  is  espe- 
cially serviceable  if  used  at  night  when  the  patient  is  unable 
to  obtain  rest.  The  application  of  hot  poultices,  hot-water 
bags,  or  sacks  containing  hot  salt  over  the  sacrum,  coccyx,  and 
ano-gluteal  region  add  much  to  the  patient's  comfort. 

The  use  of  cold  water  or  ice  is  highly  spoken  of  by  some 
authorities,  but  in  the  writer's  experience  it  has,  except  in  a 


310  DISEASES  OF  THE  RECTUM  AND  ANUS 

few  cases,  added  to  the  patient's  discomfort  by  stimulating 
contractions  of  the  sphincter-muscle. 

In  addition  to  the  above  agents,  the  most  reliable  remedies 
for  the  relief  of  pain  and  sphincteralgia  are  solutions,  oint- 
ments, and  suppositories  containing  opium,  morphine,  bella- 
donna, conium,  geranium,  chloral  hydrate,  potassium  bromide, 
orthoform,  eucaine,  cocaine,  or  other  local  anesthetic;  or 
hamamelis  or  Goulard's  extract  for  their  soothing  effect. 

In  the  author's  practice  the  following  ointment  has  proven 
efifective  in  most  cases : — 

IJ  Hydrarg.  chlor.  mit., 

Ext.  belladonnse    aa  3j  41 

Ungt.  stramonii ad  §j  30 

Misce  et  fiat  unguentum. 

Sig. :    Apply  as  often  as  necessary. 

IJ  Morphinse  sulphatis   gr.  V*        015 

Ext.  belladonnee gr-  Vz        03 

Lanolini   3j  4 

M.     Sig.:    Apply  at  once  and  repeat  as  often  as  necessary. 

The  injection  of  a  small  quantity  of  warm  starch-water 
containing  20  to  30  drops  of  laudanum  can  also  be  recom- 
mended, or  the  following  may  be  frequently  applied : — 

IJ  Cocainse   hydrochlor gr.  vj        36 

Ext.  belladonnse 3ij  8 

Ext.  opii, 

Glycerin!    aa '  3j  41 

M.     Sig.:    Apply  on  cotton  pledget. 

Allingham  speaks  highly  of  the  following  for  its  anodyne 
effect : — 

I^  Hydrargyri  subchloridi  gr.  iv        124 

Pulvis  opii, 

Ext.  belladonnse    aa  gr.  ij  12 

Ungt.  sambuci   3j  4 

M.     Sig.:    Apply  frequently. 

When  flatulence  is  a  troublesome  concomitant  of  painful 
ulcer,  it  may  be  relieved  by  inserting  a  small  rectal  tube  into 
the  anus  and  allowing  the  gas  to  escape ;  this  may  be  done  at 
intervals,  or  the  tube  may  be  kept  constantly  in  the  rectum 
until  the  flatulence  is  relieved. 


TKEATMENT  OF  ANAL  FISSURE  31I 

Stimulation  of  the  ulcer  will  in  most  cases  effect  a  cure 
if  properly  done.  In  order  to  reduce  the  pain  accompany- 
ing and  following  these  procedures  it  is  necessary  to  anesthe- 
tize the  ulcer  by  the  use  of  cocaine  or  eucaine  or  by  freezing 
with  ethyl  chloride,  the  ether-spray,  or  liquid  air.  The  co- 
caine should  be  used  in  6-per-cent.  solution  and  the  eucaine 
in  4-per-cent.  soli^tion,  and  applied  directly  to  the  ulcer  on  a 
pledget  of  cotton.  The  ulcer  should  be  thoroughly  cleansed 
prior  to  the  application.  The  most  reliable  stimulating  agents 
in  the  treatment  of  painful  ulcer  are  solutions  of  silver  nitrate 
(2  to  6  per  cent),  ichthyol  (10  to  25  per  cent.),  balsam  of  Peru 
(25  to  50  per  cent.),  argonin  (15  per  cent.),  zinc  sulphate  (4 
per  cent.),  and  alum  (25  to  50  per  cent.).  These  agents  should 
be  used  two  or  three  times  a  week  and  oftener  if  necessary,  or 
they  may  be  applied  on  pledgets  of  cotton  and  left  in  contact 
with  the  ulcer.  Of  these,  silver  nitrate  has  given  the  best  re- 
sults. Bodenhamer  says:  "It  lessens  or  calms  the  nervous  irri- 
tation w^hich  so  powerfully  tends  to  induce  spasmodic  contrac- 
tion of  the  sphincter,  it  coats  and  shields  the  raw  and  exposed 
mucous  surface,  it  removes  the  diseased  and  morbid  action  of 
the  parts,  and  it  destroys  the  hard  or  callous  edges." 

The  following  remedies  in  the  form  of  ointrents,  lotions, 
dusting-powders,  or  suppositories  have  also  given  good  results 
in  the  author's  practice:  Orthoform,  analgine,  aristol,  calomel, 
ferri  sulphate,  soda  salicylate,  ichthyol,  zinc  oxide,  bismuth  sub- 
nitrate,  mercuric  oxide,  bismuth  subiodide,  zinc  stearate  (either 
alone  or  with  iodoform  or  balsam  of  Peru),  silver  citrate  or 
lactate,  tannic  acid,  and  orthoform. 

Lotions  and  ointments  are  preferable  to  insoluble  powders 
and  suppositories,  because  the  former  tend  to  cake  within  the  ulcer 
and  produce  irritation,  and  the  latter,  when  soft,  are  difficult 
to  introduce  and  when  hard  act  as  a  foreign  body  in  the  rec- 
tum, causing  additional  suffering. 

The  author  has  been  well  pleased  with  the  results  obtained 
by  the  use  of  the  following  dusting-powder : — 

IJ  Hydrargyri  chloridi  mitej 

Zinci  stearatis  cum  balsami  Peruv aa  3ij  81 

Sodii   salicylatis 3j  4| 

M.     Sig. :      Dust  over  the  ulcer  daily. 

Mathews  is  partial  to  iodoform  in  the  following  combina- 
tion : — 


312  DISEASES  OF  THE  EECTUM  AND  ANUS 

I>  Vaselini    Sj  301 

lodof ormi    3j  4 

Acidi  carbolici   gi'.  xxx      2 

M.     A  small  portion  to  be  used  each  day  with  the  ointment-carrier. 

Andrews  suggests  the  use  of  the  following  in  the  treat- 
ment of  fissure : — 

I^  lodof  ormi    3j  4 

Ungt.  belladonna;    Bss         15 

Acidi  carbolici   gr.  x  65 

Cosmolini     Bss         15 

M.     Sig. :    To  be  used  daily. 

Cauterization  is  indicated  in  painful  ulcers  which  have  re- 
fused to  yield  to  cleansing  and  stimulating  treatment.  In  such 
cases  the  fissure  should  be  ecuconized  and  thoroughly  cauterized 
with  the  Paquelin  cautery-point  or  with  the  well-known  chemic 
caustics :  potential  silver,  nitric  or  carbolic  acid,  liquor  potassse, 
or  copper  sulphate.  In  the  majority  of  cases  one  cauterization 
will  suffice,  but  in  persistent  cases  it  will  be  necessary  to  repeat 
it  two  or  more  times. 

When  a  fissure  is  due  to  eczema,  resorcin  ointment  gives 
good  results.  In  children,  when  caused  by  threadworms,  a  few 
injections  of  lime-water  or  salt  solution  will  destroy  the  worms, 
and  then  the  ulcer  as  such  may  be  treated. 

SURGICAL   TREATMENT 

Surgical  treatment  is  always  successful  in  uncomplicated 
painful  ulcer.  It  is  the  quickest  method  of  cure,  comparatively 
painless,  and  accompanied  by  little  danger.  The  following 
operations  have  their  respective  adherents.  Any  one  of  them 
will  usually  effect  a  cure : — 

1.  Divulsion.  2.   Division. 

3.   Excision. 

Boyer  was  the  first  to  demonstrate  that  fissure  in  ano 
could  be  cured  by  cutting  the  sphincter-muscle,  and  Recamier, 
in  an  article  entitled  "Massage  Cadence,"  published  in  1838, 
suggested  stretching  of  the  anus  and  massage  of  the  sphincter- 
muscle  by  manipulation  between  the  thumb  and  finger  until  it 
became  relaxed.  Maisonneuve,  in  1864,  was  the  first  to  advise 
forcible  divulsion.     His  method  of  procedure  was  to  oil  the 


TREATMENT  OF  ANAL  FISSURE  313 

hand  and  gradually  introduce  it  into  the  rectum ;  when  the 
whole  hand  had  entered,  it  was  closed  and  the  fist  forcibly- 
withdrawn,  thus  thoroughly  stretching  the  sphincter  in  every 
direction :    a  brutal  operation,  to  say  the  least. 

Divulsion  (Recamier's  operation)  has  been  greatly  modi- 
fied since  Recamier  first  suggested  it.  As  practiced  to-day,  it 
is  either  gradual  or  forcible. 

Gradual  Divulsion  should  be  selected  in  those  instances  of 
painful  ulcer  in  which  the  patient  persistently  refuses  to  sub- 
mit to  a  more  radical  operation  under  either  local  or  general 
anesthetization. 

The  operation  is  performed  in  the  following  manner: 
After  the  rectum  has  been  emptied  and  the  parts  thoroughly 
cleansed,  the  ulcer  should  be  anesthetized  by  freezing  or,  better 
still,  by  placing  in  it  a  pledget  of  cotton  saturated  with  6- 
per-cent.  cocaine  or  4-per-cent.  beta-eucaine  solution.  If  the 
structures  about  it  are  extremely  irritable,  they  should  be  in- 
jected with  either  of  these  solutions;  this  will  diminish,  but  not 
prevent,  pain  during  the  stretching.  Divulsion  may  be  done 
with  the  fingers  or  with  anal  dilators.  If  done  by  the  fingers 
they  should  be  well  oiled  or  soaped,  and,  with  the  patient  upon 
the  left  side,  the  index  finger  slowly  introduced  into  the  bowel ; 
after  the  irritation  caused  by  this  has  subsided,  the  middle 
finger  is  gradually  slipped  in  beside  the  first,  and  this  is  fol- 
lowed by  the  careful  insertion  of  the  ring  finger  and,  if  pos- 
sible, the  little  finger;  thus  the  muscle  is  gradually  divulsed. 
In  aggravated  cases  it  may  be  necessary  to  repeat  the  opera- 
tion. 

When  bougies  are  used  to  dilate  the  anus,  they  may  be 
of  tallow,  wax,  or  rubber;  the  Wales  hollow  graduated  soft- 
rubber  bougies  (Fig.  117)  are  preferable.  It  is  better  to  com- 
mence with  a  small  size, — say,  a  No.  8, — and  gradually  increase 
until  a  No.  12  can  be  easily  introduced ;  the  latter  stretches  the 
muscle  as  much  as  is  necessary.  The  same  can  be  accomplished 
by  the  "Ideal"  anal  dilators  (Fig.  113),  which  are  so  con- 
structed that  they  may  be  retained  in  situ  if  desired. 

Forcible  Divulsion  is  the  most  popular  method  of  dilating 
the  sphincter,  but  the  operation  should  never  be  performed 
except  under  general  anesthesia.  The  divulsion  should  always 
be  done  with  either  the  index  fingers  or  thumbs,  and  the  anus 


314  DISEASES  OF  THE  RECTUM  AND  ANUS 

should  be  stretched  thoroughly  in  every  direction  until  the 
muscle  is  so  relaxed  that  the  orifice  remains  open.  About  five 
minutes  are  required  for  the  operation.  The  advantage  of 
using  the  fingers  for  this  operation  is  that  any  tearing  of  the 
mucous  membrane  or  muscle  is  quickly  detected  by  the  touch, 
when  the  operator  can  change  the  direction  of  the  pressure  and 
avoid  further  damage  to  the  parts.  The  use  of  large  specula 
or  the  mechanic  dilators  devised  to  stretch  the  sphincter  is  to 
be  deprecated,  because  the  pressure  cannot  be  controlled  and 
great  damage  to  the  muscles  may  be  so  quickly  done  that  the 
operator  has  no  knowledge  of  it. 

Forcible  or  gradual  divuhion  of  the  muscle  proves  bene- 
ficial in  two  ways :  in  the  first  place,  as  a  result  of  the  relaxation 
of  the  muscle,  immediate  rest  is  obtained  and  all  spasmodic 
sphincteric  contraction  ceases;  in  the  second  place,  the  over- 
sensitiveness  disappears,  supposedly  as  a  result  of  stretching 
the  terminal  nerve-filaments,  and  because  less  resistance  is 
offered  to  the  passage  of  the  feces,  which,  consequently,  do 
not  tear  and  contuse  the  parts  as  before.  Divulsion  having 
been  accomplished,  the  ulcer  should  receive  palliative  treat- 
ment; a  cure  will  be  effected  in  from  one  to  three  weeks. 

Division  (Boyer's  operation)  is  next  to  divulsion  in  favor 
as  a  method  of  relieving  painful  ulcer.^  It  was  suggested  by 
Pare,  but  was  first  performed  by  Boyer,  who  advised  complete 
division  of  the  sphincter-muscle.  Some  years  later  Copeland 
gave  it  as  his  opinion  that  a  superficial  cut  extending  through 
the  mucous  membrane  and  but  partly  through  the  sphincter 
just  beneath  the  ulcer  was  quite  as  effective  as  the  more  radical 
method  of  Boyer.  In  the  author's  opinion,  complete  division 
of  the  muscle  is  preferable  to  Copeland's  method.  The  opera- 
tion is  simple,  effective,  requires  but  a  moment,  and  is  not 
dangerous.  It  can  be  done  under  either  local  or  general  anes- 
thesia. The  buttocks  should  be  held  apart  by  an  assistant.  The 
operator  should  expose  the  ulcer  by  separating  the  anus  with 
the  fingers  of  his  left  hand  or  with  an  operating  speculum  (Fig. 
95),  and  then  with  a  sharp  bistoury,  with  one  stroke,  cut  down 
through  the  fissure  and  divide  the  muscle.  The  cut  should  ex- 
tend a  little  way  beyond  the  ends  of  the  ulcer,  but  not  so  high 
as  to  sever  the  internal  sphincter,  because  of  the  added  danger 
of  incontinence.  The  danger  of  this  accident  is  emphasized  by 
the  opponents  of  this  operation,  but  in  the  author's  experience 

'  In  most  of  his  cases,  the  anthor  prefers  to  divide  the  muscle  under  local  anesthesia. 


TREATMENT  OF  ANAL  FISSURE 


315 


incontinence  has  never  followed  division  of  the  sphincter  for 
the  relief  of  fissure ;  he  has,  however,  treated  several  persons 
for  loss  of  sphincteric  control  caused  by  sudden  stretching  of 
the  muscle  by  mechanic  dilators. 

Dumarquay  has  suggested  submucous  division  of  the 
sphincter-muscle ;  but  his  operation  has  not  met  with  favor, 
principally  because  it  is  frequently  followed  by  infection,  ab- 
scess, and  fistula. 

Excision  is  preferred  by  some  operators,  but  the  author 
has  not  found  it  as  effective  as  either  divulsion  or  division.     It 


Fig.  95. — Gant's  Large  Operating  Speculum. 


consists  in  circumscribing  the  ulcer  by  elliptic  incisions  and  re- 
moving it.  The  wound  is  then  closed  with  catgut  sutures  or 
is  allowed  to  heal  by  granulation.  In  addition  to  excising  the 
ulcer,  the  writer  always  divides  or  divulses  the  sphincter-muscle 
in  order  that  complete  rest  of  the  parts  may  be  assured.  Ex- 
cision and  immediate  closure  of  the  wound  when  successful 
effect  a  cure  more  quickly  than  any  other  operation  for  fissure, 
but  when  infection  of  the  wound  takes  place  increased  pain 
and  abscess  follow. 

When  the  fissure  is  due  to  laceration  and  downward  dis- 
placement of  a  semilunar  valve,  forming  the  so-called  "sen- 


316  DISEASES  OF  THE  RECTU]VI  AND  ANUS 

tinel"  pile,  Ball  suggests  that  the  latter  be  removed  by  a  V- 
shaped  incision,  having  the  base  toward  the  ulcer,  so  that  noth- 
ing is  left  which  can  be  caught  by  a  passing  fecal  mass.  The 
ulcer  should  be  curetted  and  the  wound  allowed  to  heal  by 
granulation.  When  the  torn  valve  does  not  extend  downward 
as  far  as  the  anus,  all  that  is  necessary  is  to  clip  it  off  level  with 
the  mucous  membrane,  thus  removing  the  source  of  irritation. 
The  Post-operative  Treatment  of  painful  ulcer  does  not  differ 
from  that  following  other  operations  about  the  anus.  The 
patient  should  be  restricted  to  a  light  diet,  the  bowels  regu- 
lated, the  wound  cleansed  daily  and  stimulated  if  necessary. 
When  the  incision  is  deep,  drainage  is  imperative,  and  should 
be  secured  by  the  insertion  of  a  piece  of  gauze,  as  in  fistula 
cases. 

ILLTISTRATIVE   CASES 

Case  XII.  Painful  TTleer  Caused  by  Constipation. — J.  C,  aged  39,  har- 
ness-maker, came  to  my  clinic  with  the  following  history :  He  had  been  suffer- 
ing from  constipation  of  the  worst  form,  induced  by  a  sedentary  occupation 
and  irregular  habits.  He  had  but  one  stool  a  week,  and  that  as  a  result  of 
some  strong  cathartic.  Some  two  weeks  prior  to  the  time  he  applied  for 
treatment  he  had  a  large  fecal  action;  the  feces  were  hard,  irregular  in  shape, 
and  so  difficult  to  expel  that  when  forced  out  they  caused  a  tearing  sensation 
and  pain,  which  lasted  for  two  hours.  Considerable  bleeding  followed  expul- 
sion of  the  last  portion  of  feces.  From  then  until  the  time  of  operation  he  com- 
plained of  severe  pain  over  the  coccyx  and  the  loss  of  blood  during  every  act 
of  defecation.  In  addition,  for  the  last  three  days  pain,  aggravated  by  spas- 
modic contraction  of  the  sphincter-muscle,  had  been  almost  constant. 

Examination  revealed  the  presence  of  a  well-marked  painful  ulcer  just 
within  the  grasp  of  the  external  sphincter;  it  was  inflamed  and  exceedingly 
sensitive. 

Treatment. — Chloroform  was  administered,  the  sphincter  thoroughly  di- 
vulsed,  and  the  ulcer  painted  over  with  a  solution  of  silver  nitrate,  15  grains 
to  the  ounce.  The  rectum  Avas  cleansed  daily  with  carbolized  water,  and  silver 
nitrate  used  every  three  days  for  two  weeks,  at  the  end  of  which  period  the 
ulcer  was  completely  healed. 

Case  XIII.  Painful  Ulcer  with  Bladder  Complications. — Mrs.  C,  aged 
27,  was  referred  to  me  from  the  country.  She  complained  of  pain  in  the 
rectxmi,  and  also  of  some  disturbance  in  the  bladder.  She  had  constant  desire 
to  urinate.  A  careful  examination  of  the  bladder  and  urethra  was  made,  and 
they  appeared  perfectly  healthy.  The  urine  was  examined,  and  nothing  of  a 
suspicious  nature  was  found.  Attention  was  next  turned  to  the  rectum,  and 
there,  one-half  inch  (1.27  centimeters)  above  the  anus,  upon  the  posterior  wall, 
was  located  an  irritable  ulcer  the  size  of  a  split  pea,  which  proved  to  be  the 
source  of  the  irritation.  The  ulcer  was  incised  through  the  center  down  into 
the  muscle,  a  few  applications  of  balsam  of  Peru  were  made  to  the  wound, 
and  it  soon  healed.    All  bladder  disturbances  disappeared  and  never  returned. 


TREATMENT  OF  ANAL  FISSURE  317 

This  case  is  mentioned  simply  to  show  one  of  the  reflex  phenomena  of  painful 
ulcer  or  fissure. 

Case  XIV.  Painful  Ulcer  Within  External  Pile. — Mr.  H.,  a  prominent 
judge  of  Kansas  City,  came  to  me  suffering  from  complete  nervous  prostration. 
He  was  totally  unfit  to  occupy  the  bench.  He  stated  that  he  was  suffering 
from  some  exceedingly  painful  disease  of  the  rectum,  which  he  feared  might 
be  cancer,' his  mother  having  died  from  carcinoma  of  the  breast.  On  examina- 
tion a  slit-like  (Plate  XVII)  ulcer  was  found  hidden  almost  from  view  within 
the  folds  of  an  external  pile.     No  other  pathologic  condition  was  found. 

He  would  not  consent  to  anesthesia.  A  solution  of  cocaine  was  therefore 
applied  for  a  short  time,  and  a  No.  10  Wales  soft-rubber  bougie  introduced 
and  left  until  the  sphincter  relaxed  sufficiently  to  admit  the  speculum.  A 
solution  of  silver  nitrate,  15  grains  to  the  ounce,  was  then  applied.  The  treat- 
ment had  to  be  repeated  but  four  times  before  he  was  well  and  returned  to 
his  usual  duties  free  from  pain.  Within  a  short  time  his  nervous  system  was 
restored  to  its  normal  condition. 


LITERATURE  ON  PAINPUL  ULCER,  OR  FISSURE  IN  ANO 


Adler:    "Palliative  Treatment  of  Anal  Fissure,"  Mathews's  Med.  Quart.,  vol.  i, 

p.  383,  1894. 
Agnew:    "Rectal  Diseases,"  third  edition,  p.  140,  1896. 
Allingham:    "Diseases  of  the  Rectum  and  Anus,"  p.  272,  1896. 
Andrews:    "Rectal  and  Anal  Surgery,"  third  edition,  p.  152,  1892. 
Ball:    "Anal  Valves  as  Cause  of  Fissure,"  Matlieics's  Med.  Quart.,  vol.  i,  p.  191, 

1894. 

"Anal  Fissure,"  Brit.  Med.  Jour.,  ii,  p.  583,  1891. 
Blaudin:    "Diet,  de  Med.  et  de  Chir.  Pratiques"  (art.,  "Fissure"),  t.  viii,  p.  155. 

Paris,  1835. 
Bodenhamer:     "Treatise   on   Etiology,  Pathology,   Symptoms,  and  Treatment 

of  Anal  Fissure,"  1868. 
Boyer:    "Traites  des  Maladies  Chirurgicales,"  t.  vi,  p.  605,  Cinquieme. 

Ed.  Paris,  1849.    Also  J.CompIemeutaire  da  Diction,  des  Scien.  Med., 

t.  ii,  p.  24.     Paris,  1818. 
Conitzer:     "Ueber  die  Behandlung  der  Afterschrunde    (Fissure  Ani)    mit  Ich- 

thyol,"  Milncliener  med.  Woch.,  xlvi,  p.  80,  1899. 
Copeland:    Diiblin  Hospital  Gazette,  1855. 

Cripps:    "Anal  Fissure,"  Matlieics's  Med.  Quart.,  vol.  iv,  p.  228,  1897. 
Dourmer:    "Traitement  de  la  Fissure,"  Ann.  d' elect rohiologie,  etc.,  vol.  i,  p.  143. 

Paris,  1898. 
Dumarquay:    Arch.  Gen.  de  Med.,  1846. 
Dupuytren:   "Le  cous  Orales  de  Clin.  Chir.,"  t.  iii.  Art.  10,  De  la  Fissure  Theses, 

de  Strasbourg,  1829. 
Einhorn:    "Anal  Fissures,"  "Diseases  of  the  Intestines,"  p.  193,  1900. 
Gerster:    "Fissures  in  Ano,"  Mathews's  Med.  Quart.,  vol.  i,  p.  134,  1894. 
Goodsall:    "Anal  Fissure,"  St.  Bartholomew's  Hosp.  Reports,  t.  xxviii,  p.  205, 

1892. 


318  DISEASES  OF  THE  RECTUM  AND  ANUS 

Goodsall  and  Miles:  "Anal  Fissure,"  "Diseases  Anus  and  Rectum,"  Pt.  I,  p.  206, 
1900, 

Gross:  "Anal  Fissure,"  "A  System  of  Surgery,"  vol.  ii,  p.  736.  Philadelphia, 
1859. 

Koplik:   "Anal  Fissures  in  Children,"  Mathews's  Med.  Quart.,  vol.  i,  p.  29,  1894. 

Le  Dentu  and  Delbet:    "Traite  de  Chirurgie,"  vol.  viii,  p.  450,  1899. 

Maisonneuve:    "Clinique  Chirurgicale,"  t.  ii.    Paris,  1864. 

Malgaigne:  "Operative  Surgery";  English  version  by  Brittan,  p.  429.  Phila- 
delphia, 1851. 

Mason:    "Anal  Fissures,"  2V^.  Y.  Med.  Record,  ix,  p.  585,  1874, 

Nelaton:  "Anal  Fissures,"  "Clin.  Lecture  on  Surgery."  Notes  by  Johnson, 
p.  552.     Philadelphia,  1859. 

Pare:    The  vrorks  of ;   English  version  by  Johnson ;   Ixiii,  p.  954.    London,  1854. 

Piatt:  "Pathology  and  Treatment  of  Anal  Fissure,"  Med.  Chronicle,  Man- 
chester, ix,  p.  32,  1898. 

Quenu:   Revue  de  Chirurgie,  p.  988,  1892. 

Quenu  and  Hartmann:  "SymptSmes  et  Diagnostic  Chirurgie  du  Rectum,"  p. 
424,  1895. 

Recamier:    "Massage  Cadencg"  Revue  M6d.  de  Paris,  Janvier,  1838. 

Stewart:    "Anal  Fissures,"  Mathews's  Med.  Quart.,  vol.  ii,  p.  75,  1895. 

Van  Buren:  "Treatment  of  Diseases  of  the  Rectum,"  Amer.  Med.  Times,  vol, 
viii,  p.  218,  1864. 

Van  Herff:  "Aetiologie  und  Pathogenese  der  Fissura  Ani,"  Milnchener  med. 
Woch.,  xliv,  p.  976,  1897. 

Velpeau:    "Anal  Fissure";    Mott's  "Velpeau,"  vol.  iii,  p.  1108,  1847. 


PLATE    XVIIL— ULCERATION    OF    THE    RECTUM    AND    POLYPOID- 
LIKE   SENTINEL  TEATS  [Diagrammatic^. 


CHAPTER  XXIII 

NON=MALIQNANT  ULCERATION  AND  ESTHIOMENE 

Painful  ulcer  (fissure)  having  been  the  subject  of  the 
preceding  chapter,  the  present  chapter  will  be  devoted  to  the 
discussion  of  other  forms  of  non-malignant  ulceration. 

The  majority  of  writers  maintain  that  ulceration  of  the 
rectum  occurs  much  more  frequently  in  women  than  in  men. 
■This,  they  claim,  is  due  to  injury  to  the  rectum  during  partu- 
rition, pressure  of  the  bowel  against  the  bony  structures  in 
retroversion  of  the  uterus,  and  to  the  fact  that  women  suffer 
more  often  from  constipation.  In  the  author's  experience,  how- 
ever, ulceration  in  the  ano-rectal  region  is  almost  as  common 
in  men  as  in  women,  but  the  disease  is  apt  to  be  more  extensive 
and  difficult  to  manage  in  women,  owing  to  the  complications 
stated  above.  Except  painful  ulcer  and  the  fissured  condition 
accompanying  congenital  syphilis  and  proctitis,  children  rarely 
suffer  from  ulceration  of  the  rectum. 

Ulcers  of  the  ano-rectal  region  may  be  superficial  or  deep, 
large  or  small,  single  or  multiple,  acute  or^clironic,  circular  or 
irregular  in  shape;  they  may  be  situated  inlhe  skin  about  the 
anal  margin,  in  the  anal  canal,  or  in  any  part  of  the  upper  rec- 
tum, and  may  cause  slight  or  the  most  excruciating  pain. 

ETIOLOGY   AND  PATHOLOGY 

From  an  etiologic  stand-point  the  usual  forms  of  ulcera- 
tion in  the  ano-rectal  region  may  be  classified  as  follows : — 

1.  Traumatic.  4.  Tubercular. 

2.  Venereal.  5.  Dysenteric. 

3.  Catarrhal.  6.  Varicose  (hemorrhoidal). 

Among  the  rarer  causes  of  ulceration  of  the  rectum  and 
anus  are  uremia,  sublimate  poisoning,  Bright's  disease,  ty- 
phoid fever,  diabetes,  starvation,  drastic  purgatives,  chronic 
intestinal  discharges,  prurigo,  eczema,  psoriasis,  herpes,  and 
extension  of  diseases  from  neighboring  organs. 

Traumatic  Ulceration  is  quite  common  and  frequently 
caused  by  constipation;  the  mucous  membrane  may  be  torn 
in  the  attempt  to  expel  a  large,  nodular  fecal  mass,  or  the 

(319) 


320  DISEASES  OF  THE  RECTUM  AND  ANUS 

retained  feces  may  press  the  rectum  back  against  the  bony 
structures,  causing  direct  injury  or  interfering  with  the  circula- 
tion and  resulting  in  necrosis.  Again,  traumatic  ulcers  may 
be  the  result  of  operations  for  the  relief  of  hemorrhoids,  fistula, 
stricture,  cancer,  prolapse,  or  other  rectal  disease;  or  it  may 
be  induced  by  operations  upon  the  uterus,  vagina,  bladder, 
urethra,  or  prostate.  Other  causes  of  this  form  of  ulceration 
are  pederasty,  deviated  coccyx,  foreign  bodies  in  the  rectum, 
injury  to  the  bowel  during  labor;  improper  use  of  the  syringe 
nozzle,  bougies,  mechanic  dilators,  or  other  instruments ;  the 
application  of  escharotics;  the  injection  treatment  of  piles  or 
fistula  where  strong  irritating  fluids  are  injected  into  the  tis- 
sues. Frequent  handling  and  replacing  of  prolapse,  polyps, 
hemorrhoids,  or  other  tumors  which  protrude  often  cause 
ulceration  of  the  mucosa.  In  exceptional  cases  ulceration  is 
the  result  of  injury  from  external  violence,  kicks,  falls,  stab  or 
gunshot  wounds,  etc. 

Depending  upon  the  general  condition  of  the  patient,  the 
character  of  the  injury,  and  the  treatment  it  has  received,  trau- 
matic ulceration  may  be  slight  and  amenable  to  treatment  or 
extensive  and  extremely  difficult  to  heal.  Exposure  to  infec- 
tion, stretching  and  irritation  of  the  parts  by  the  passage  of 
feces  and  lodgment  of  fruit-seeds,  fecoliths,  or  other  small  for- 
eign bodies  within  the  ulcers,  tend  to  prolong  and  favor  ex- 
tension of  ulceration.  The  largest  and  deepest  traumatic 
ulcers  are  those  which  follow  rectal  operations,  especially  such 
as  are  performed  for  the  relief  of  fistula  and  stricture,  in  which 
extensive  cutting  is  done  and  healing  is  delayed  or  arrested  by 
too  frequent  and  tight  packing  or  excessive  stimulation  of  the 
wounds. 

Venereal  Ulceration  of  the  rectum  is  not  encountered  in  this 
country  as  frequently  as  in  France,  Asia,  and  other  Eastern 
countries  where  sodomy  is  widely  practiced.  This  variety  of 
ulceration  may  be  caused  by  syphilis,  chancroids,  and  some- 
times gonorrhea. 

Rectal  ulceration  caused  by  syphilis,  either  congenital  or 
acquired  is  not  uncommon  and  may  occur  at  any  age.  Per- 
sons suffering  from  syphilis  are  particularly  susceptible  to 
ulceration  of  the  rectal  region ;  indeed,  cHnicians  have  not  in- 
frequently observed  that  simple  abrasions  and  minor  injuries, 
which  heal  quickly  in  healthy  individuals,  often  cause  in  syph- 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  331 

ilitic  subjects  an  extensive  ulceration  which  is  extremely  diffi- 
cult to  manage. 

True  Syphilitic  ulceration  of  the  rectum  may  result  from 
chancres,  mucous  patches,  or  breaking  down  of  gummatous 
deposits.  Chancres,  which  are  not  common  about  the  rectum, 
are  generally  due  to  direct  infection.  They  occur  much  more 
frequently  in  women  than  in  men,  are  usually  located  near  the 
anus,  but  may  appear  on  the  perineum  or  buttocks.  When 
external  to  the  anus,  chancres  in  this  region  do  not  differ  from 
those  occurring  about  the  genitals  except  that,  owing  to  fric- 
tion of  the  parts,  they  are  more  highly  inflamed.  When 
located  within  the  anus,  they  soon  terminate  in  ulceration  or  a 
fissured  condition,  dependent  upon  constant  irritation  induced 
by  the  passage  of  feces.  They  cause  comparatively  little  pain, 
and  when  properly  treated  usually  heal  quickly,  leaving  but 
small  cicatrices. 

Mucous  Patches  are  infective,  usually  multiple,  and  may 
appear  in  any  part  of  the  rectum  or  skin  about  the  anus.  They 
occur  most  frequently  at  the  muco-cutaneous  junction  and 
between  the  radiating  folds.  They  are  generally  small,  flat, 
rounded,  and  grayish  in  color,  but  they  may  also  be  elevated 
and  highly  colored.  As  a  result  of  irritation  they  soon  become 
ulcerated,  and  exude  an  offensive,  auto-inoculable,  mucoid  dis- 
charge, which  keeps  the  parts  constantly  moist.  If  allowed  to 
collect  and  decompose,  this  discharge  induces  hypertrophic 
changes  of  the  papillae,  resulting  in  wart-like  excrescences 
(condylomata  lata).  The  most  obstinate  cases  of  mucous 
patches  in  the  ano-rectal  region  treated  by  the  writer  were  due 
to  congenital  syphilis.  The  lesions  had  become  long,  deep 
fissures,  involving  both  the  skin  and  mucosa.  If  recognized 
early  and  while  in  the  superficial  stage,  ulcerated  mucous 
patches,  unless  complicated,  yield  easily  to  proper  constitu- 
tional and  local  treatment  and  heal  within  a  few  weeks,  leaving 
but  little  scar;  if  complicated  by  chancroidal  ulceration,  how- 
ever, they  may  become  phagedenic  in  character  and  produce 
rapid  destruction  of  tissue.  When  improperly  treated  or  per- 
mitted to  run  an  uninterrupted  course,  they  become  chronic, 
extensive,  and  deep,  sometimes  involving  the  mucous  and  mus- 
cular coats ;  even  now  they  may  respond  to  proper  treatment 
and  heal  gradually,  but,  owing  to  the  great  amount  of  inflam- 
mation and  thickening,  or  extensive  cicatricial  formation,  com- 

21 


322  DISEASES  OF  THE  RECTUM  AND  ANUS 

plete  or  partial  stricture  may  be  produced.  Again,  ulceration 
may  progress  and  terminate  in  perforation  of  the  bowel-wall, 
followed  by  perirectal  abscess  and  fistula. 

In  a  case  which  was  some  years  ago  referred  to  the  author 
for  examination  there  were  numerous  mucous  patches  in  the 
anal  canal,  some  of  which  were  ulcerated.  A  number  of 
months  later  the  ulcers  had  become  extensive  and  deep,  and 
had  evidently  coalesced  so  as  almost  completely  to  encircle  the 
bowel. 

In  a  second  case  of  syphilitic  ulceration  occurring  in  a 
prostitute,  25  years  of  age,  the  ulcers  were  fissure-hke  and  an 
inch  (2.54  centimeters)  in  length.  One  situated  upon  the  ante- 
rior rectal  wall  was  so  deep  that  the  fibers  of  the  sphincter- 
muscle  could  be  seen  crossing  its  base. 

Single  or  multiple  gummatous  deposits  in  the  submucosa 
may  cause  superficial  ulcers  involving  the  mucosa  as  a  result 
of  the  obstruction  to  the  circulation  and  irritation  induced  by 
the  passage  of  feces.  When  the  gummy  deposits  have  disin- 
tegrated these  ulcers  become  deep  and  crater-like  and  dis- 
charge an  abundant  secretion  composed  of  pus,  blood,  and 
mucus.  In  spite  of  treatment  such  ulcers  manifest  a  tendency 
to  extend  and  destroy  a  large  area  of  the  mucosa  and  sub- 
mucosa, and  they  may  involve  even  the  muscular  coat.  As 
healing  takes  place,  the  typic,  unyielding,  tight  stricture,  so 
frequently  described,  is  produced.  A  rare  form  of  syphilitic 
ulceration  due  to  perirectal  gummata  may  extend  to  the  rec- 
tum and  result  in  abscess  and  the  formation  of  sinuses  leading 
from  the  rectum  to  neighboring  organs  or  the  surface  of  the 
body  (see  chapter  on  venereal  diseases). 

Chancroidal  Ulcers  are  the  most  common  and  painful  form 
of  venereal  ulceration  of  the  ano-rectal  region.  Chancroids 
about  the  anus  and  rectum  are  usually  multiple  and  situated 
anteriorly  at  the  muco-cutaneous  junction;  but  they  may  be 
located  high  up  in  the  rectum,  or  sometimes  in  the  perineum. 
They  occur  far  more  frequently  in  women  than  in  men,  and 
are  most  common  to  prostitutes  and  sodomists. 

The  general  appearance  of  chancroids  in  this  region  is 
similar  to  that  of  chancroids  about  the  genitals,  except  that 
their  location  between  the  folds  of  skin  and  mucous  membrane 
about  the  anus,  together  with  the  action  of  the  sphincter-mus- 
cle, causes  the  ulcers  to  become  elongated  and  resemble  fis- 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE 


333 


sures,  for  which  they  are  often  mistaken.  Chancroidal  ulcers 
are  at  first  superficial,  have  sharply-defined,  undermined  edges, 
are  extremely  sensitive,  and  produce  a  profuse,  purulent  dis- 
charge. 

Conditions  in  this  region  favor  the  self-propagation  of 
chancroids.  This,  in  conjunction  with  the  stretching  incident 
to  defecation  and  exposure  to  infection,  causes  them  to  spread 
and  become  so  extensively  and  deeply  ulcerated  that  healing 
may  result  in  partial  or  complete  stricture.  In  persons  consti- 
tutionally zveak,  if  cleanliness  is  not  strictly  observed,  chan- 
croidal ulcers  may  become  phagedenic,  and  result  in  the  slow 


Fig.  96.— Primary  Tuberculosis  of  the  Rectum  and  Anus, 
Tubercular  Deposits. 


3hovv^iiig 


or  rapid  destruction  of  much  tissue.  When  gradual,  this  con- 
dition may  resemble  epithelioma  or  lupus  and  easily  be  mis- 
taken for  either. 

GouorrJiea  of  the  rectum  always  causes  a  superficial  ulcera- 
tion or  chafed  condition  of  the  mucosa,  because  of  the  irri- 
tating nature  of  the  discharge.  This  superficial  ulceration 
usually  heals  as  the  disease  subsides.  If,  however,  the  inflam- 
mation is  allowed  to  become  chronic,  ulcers  of  considerable 
size  may  be  formed,  which  leave  a  corresponding  cicatrix  when 
finally  healed. 


324  DISEASES  OF  THE  RECTUM  AND  ANUS 

Catarrhal  Ulceration  is  secondary  to  acute  or  chronic  proc- 
titis, and  is  due  to  obstructed  cnxulation  and  the  action  of  the 
acrid  discharge  upon  the  mucosa,  furthered  by  irritation  from 
the  passage  of  feces.  From  a  clinic  stand-point  there  are  three 
varieties  of  catarrhal  ulceration :  (a)  simple  erosion  of  the 
mucous  membrane,  occurring  usually  in  acute  proctitis;  (b) 
the  fissured  condition  of  chronic  atropine  proctitis;  and  (e)  the 
more  or  less  extensive  ulcers  which  are  common  in  the  later 


/ 


Fig.  97. — Primary  Tuberculosis  of  the  Skin  and  Mucous  Membrane 
at  the  Anal  Outlet. 

stages  of  chronic  hypertrophie  proctitis  and  which  may  be  com- 
plicated by  polypoid-like  growths  (Plate  XVIII). 

Tubercular  Ulceration  is  frequently  encountered  in  the  ano- 
rectal region  (Plate  XIX),  and  is  usually  secondary  to  tuber- 
culosis in  some  other  part  of  the  body,  especially  phthisis 
pulmonalis.  On  the  other  hand,  it  may  be  primary  (Figs.  96 
and  97),  the  infection  having  been  introduced  directly  or  with 
the  food;  this,  however,  is  extremely  rare.  It  may  attack  any 
part  of  the  rectum,  or  the  skin  about  the  anus ;  its  most  usual 
location,  however,  is  at  the  muco-cutaneous  junction. 

Of  the  31  cases  recorded  by  Ouenu  and  Hartmann,  the 


I 

I 


8 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE 


325 


disease  extended  through  the  anal  canal  in  all  but  2,  which 
were  cutaneous.  Tubercular  ulcers  of  the  rectum  may  be 
single  or  multiple,  large  or  small,  superficial  or  deep.  Men 
suffer  from  them  more  often  than  women,  and  they  are  most 
common  in  young  adults.  Of  31  cases  reported  by  Quenu 
and  Hartmann,  24  were  men,  6  women,  and  1  child,  sex  not 
given. 

Ulceration  of  the  rectum  in  tubercular  subjects  is  of  two 
kinds:  (a)  simple  ulceration,  occurring  in  persons  suffering 
from  general  tuberculosis,  and  (b)  ulcers  due  to  the  breaking 
down  of  local  tubercular  deposits.      In  the  first  variety   there 


Fig. 


-Lupus  of  the  Anus  in  Young  Boy   (Unusual). 


are  no  local  deposits ;  the  ulceration  is  simple,  of  traumatic 
origin,  and  extremely  difficult  to  heal  on  account  of  the  debili- 
tated condition  of  the  patient.  In  the  second  variety,  or  true 
tubercular  ulceration,  miliary  tubercles  are  formed  in  the  skin, 
subcutaneous  tissue,  or  submucosa.  After  a  time  caseation 
begins ;  they  break  down  and  form  small  ulcers.  In  a  short 
time  other  deposits  are  formed  in  and  around  these  ulcers, 
and  these,  in  turn,  break  down,  extending  the  ulceration.  In 
this  way  several  of  these  ulcers  may  coalesce,  until,  finally,  the 
ulceration  almost,  if  not  completely,  encircles  the  bowel.  Tu- 
bercular ulcers  are  characterized  by  their  irregular  shape ; 
smooth,  glazed  appearance;  infiltrated  borders;  undermined 


326 


DISEASES  OF  THE  RECTUM  AND  ANUS 


edges,  and  tendency  to  extend  superficially  and  deeply  and 
become  chronic.  They  may  be  quite  superficial,  follicular,  or 
sufficiently  deep  to  perforate  the  bowel  and  cause  peritonitis 
or  ischio-rectal  abscess  and  fistula.  On  account  of  the  function 
of  the  rectum  and  the  nature  of  the  disease,  tubercular  ulcera- 
tion rarely  heals.  When  healing  does  occur,  there  may  be 
sufficient  contraction  to  produce  partial  or  complete  stricture. 
In  rare  cases  of  tuberculous  ulceration  at  the  anal  margin  in 
which  the  disease  progresses  rapidly  and  the  parts  are  not  kept 


Y\g.  99.— Tuberculosis  of  the  Mesenteric  Lymph-nodes.  Photograph  Taken 
by  the  Author  from  a  Specimen  in  Carnegie  Laboratory,  Through  the 
Kindness  of  Dr.  McAIpin. 

thoroughly  cleansed,  the  papillae  of  the  skin  become  hyper- 
trophied  and  branch  upward,  resembhng  condylomata;  this 
condition  is  known  as  tuberculosis  verrucosa,  and  has  been  con- 
fused with  papillomata  and  epitheliomata.  Again  it  may  as- 
sume a  lupoid  character  (see  Dr.  Allen's  case,  Fig.  98).  Quenu 
and  Hartmann  have  cited  but  three  cases  of  verrucous  tubercu- 
losis of  the  anal  region, — two  in  their  own  practice,  and  one 
reported  by  Routier  and  Toupet.  In  one  of  these  the  process 
was  essentially  cutaneous;  in  the  others  it  extended  into  the 
rectum.    Tubercular  excrescences  about  the  rectum  closely  re- 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  327 

semble  tuherculosis  verrucosa  cutis  in  other  parts  of  the  body. 
Tuberculosis  not  infrequently  attacks  the  mesenteric  lymph- 
nodes  in  the  perirectal  region  (Fig.  99)  and  in  distant  parts. 

Dysenteric  Ulceration  is  comparatively  rare  in  North  Amer- 
ica, but  is  frequently  encountered  in  tropic  countries.  Ulcera- 
tion of  the  rectum  is  often  diagnosticated  as  dysenteric  because 
the  patient  has  frequent  stools  containing  blood  and  mucus. 
In  reality,  the  ulceration  is  secondary  to  a  chronic  proctitis  or 
other  ulcerative  disease  of  the  colon  or  rectum,  and  the  bloody 
discharges  are  due  to  the  ulceration. 

The  author  has  seen  but  few  cases  which  he  was  satisfied 
were  true  dysenteric  ulceration.  One  of  these  was  a  naval  officer 
who  had  lately  been  stationed  in  a  tropic  country,  and  another 
was  that  of  a  planter  from  Louisiana.  Woodward's  statistics 
show  that,  out  of  the  total  number  of  cases  of  dysentery  and 
chronic  diarrhea  occurring  among  the  Union  soldiers  during 
the  Civil  War,  there  was  no  record,  either  during  the  war  or 
up  to  1879,  of  any  case  of  stricture  due  to  dysenteric  ulceration. 

Epidemic  dysentery  is  undoubtedly  due  to  a  specific  poi- 
son, the  exact  nature  of  which  is  unknown.  It  would  appear 
that  all  such  epidemics  are  not  caused  by  the  same  virus. 
Ziegler  says :  "Some  at  least  of  the  epidemic  forms  are  due  to 
bacterial  infection;  among  the  epidemics  that  have  occurred 
in  Europe,  certain  have  been  so  intimately  associated  with  bac- 
terial invasion  of  the  intestine  that  the  causal  connection  of 
the  micro-organisms  with  the  disease  can  hardly  be  doubted. 
The  micro-organisms  in  question  are  minute  bacilli,  and  they 
are  scattered  or  aggregated  within  the  glands,  the  glandular 
epithehum,  and  the  connective  tissue.  Their  multiphcation  in 
the  tissues  is  followed  by  inflammation,  necrosis,  and  degenera- 
tion. The  observations  of  Kartulis,  Kruse,  Pasquale,  Osier, 
Roos,  and  others  have  rendered  it  probable  that  a  variety  of 
dysentery  exists  which  is  caused  by  amebce,  and  that  this 
amebic  dysentery  occurs  chiefly  in  Egypt  and  Greece,  though 
it  is  also  met  with  in  other  countries,  such  as  Russia,  Germany, 
North  America,  etc." 

Ziegler  vividly  describes  the  changes  which  take  place 
within  the  structures  of  the  intestine  as  follows:  "The  in- 
tensity and  extent  of  the  dysenteric  inflammation  vary  in  dif- 
ferent cases.  It  may  be  restricted  to  the  rectum,  sigmoid 
flexure,  and  descending  colon,  or  it  may  reach  up  to,  or  even 


3^8  DISEASES  OF  THE  RECTUM  AND  ANUS 

a  little  beyond,  the  ileo-cecal  valve.     Often,  too,  in  the  same 
case  the  various  parts  of  the  tract  are  variously  affected. 

"In  recent  cases  the  mucous  membrane  is  highly  con- 
gested and  swollen,  and  generally  beset  with  minute  extravasa- 
tions of  blood.  The  epithelial  surface  is  overlaid  with  glairy, 
blood-streaked  mucus.  This  presently  becomes  more  puriform 
and  blood-stained,  and  interspersed  with  the  flaky  fibrinous 
shreds  and  films  which  indicate  the  beginning  of  superficial 
necrosis  of  the  mucous  membrane.  Soon,  the  necrosis  is  made 
sufficiently  evident  by  the  appearance  of  erosions  and  losses  of 
substance. 

"We  might  perhaps  distinguish  a  catarrhal  and  a  diph- 
theritic form  of  dysenteric  inflammation,  but  in  practice  the 
one  passes  insensibly  into  the  other  and  the  distinction  is  in- 
appreciable. In  slighter  cases  the  necrosis  and  loss  of  sub- 
stance are  at  first  merely  superficial ;  but  the  deeper  structures 
are  successively  attacked,  and  in  severe  cases  the  greater  part 
or  the  whole  of  the  glandular  layer  of  the  mucous  membrane 
at  particular  spots  perishes.  The  necrotic  tissue  is  reduced  to 
a  turbid,  granular  mass  in  which  the  structural  elements  and 
the  nuclei  of  the  cells  soon  cease  to  be  recognizable.  The  parts 
which  undergo  necrosis  are  generally  confined  to  the  promi- 
nent ridges  and  folds  of  the  mucous  membrane ;  these  appear 
dirty,  gray,  or  black,  while  the  intervening  parts  are  still  livid 
or  dark  red.  In  other  cases  the  necrotic  tissue  takes  the  form 
of  a  more  or  less  adherent  flaky  coating  or  more  rarely  of 
broad,  continuous  sloughs.  The  underlying  tissue  is,  in  all 
cases,  densely  infiltrated  with  cells.  The  infiltration  occasion- 
ally extends  through  the  entire  thickness  of  the  submucosa 
and  at  length  invades  the  muscular  layers.  The  lymphadenoid 
follicles  also  take  part  in  the  process,  and  frequently  ulcerate. 
Occasionally  a  portion  of  the  mucosa  is  undermined  by  ulcera- 
tion beneath  it,  and  in  this  way  broad  patches  of  the  tissue  are 
separated  and  cast  oflf. 

"When  portions  of  the  mucosa  are  thus  removed,  open 
ulcers  are,  of  course,  left  behind.  These  vary  much  in  depth 
and  extent ;  sometimes  the  mucous  membrane  persists  only  in 
narrow  strips  and  islands  over  a  great  part  of  the  bowel. 
Amebic  dysentery  is  said  to  be  characterized  by  the  formation 
of  small,  circumscribed  ulcers  with  undermined  edges. 

"The  affection  may  come  to  a  stand-still  at  various  stages 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  329 

of  its  course,  and  repair  then  begins.  The  sHghter  cases,  in 
which  but  httle  substance  is  lost,  are  naturally  the  readiest  to 
heal;  but  a  certain  amount  of  atrophy  of  the  mucosa  always 
remains.  When  the  ulcerative  process  has  advanced  farther, 
atrophic  cicatrices  are  left  to  mark  the  site  of  the  injury.  In 
several  cases  accompanied  by  great  destruction  of  tissue  in 
which  the  acute  specific  process  is  succeeded  by  chronic  in- 
flammation, the  whole  structure  of  the  bowel  is  altered  in  a 
remarkable  way.  The  glandular  layer  is  almost  or  altogether 
absent  over  broad  areas ;  the  deeper  layers  of  the  mucosa  and 
submucosa  are  tough  and  indurated ;  the  connective  structures 
are  hyperplastic ;  and  the  other  coats  are  likewise  dense,  thick- 
ened, and  unyielding.  The  lumen  of  the  intestine  is  usually 
narrowed,  often  to  such  an  extent  that  a  finger  can  hardly  be 
introduced.  The  mucous  membrane  is  recognizable  only  here 
and  there  in  isolated  patches,  and  these  not  infrequently  as- 
sume the  form  of  papillary  or  polypous  outgrowths  from  the 
general  surface.  Small  cysts  lined  with  cylindric  epithelium  are 
frequently  formed  by  dilatation  of  glandular  tubules  which 
have  become  obstructed  and  occluded.  There  is  also  accu- 
mulation of  secretion  in  ulcerous  cavities  that  have  become 
covered  over  with  epithelium.  This  condition  is  usually  ac- 
companied by  abundant  muco-purulent  discharge  from  the 
diseased  surfaces,  and  constitutes  what  is  clinically  described 
as  chronic  dysentery  or  'celiac  Hux.'  " 

Varicose  Ulceration  is  of  common  occurrence,  and  in  many 
respects  resembles  similar  ulcers  of  the  lower  extremity.  The 
upright  position  of  man,  the  function  of  the  rectum,  and  the 
free  distribution  in  this  region  of  veins  which  have  no  valves, 
but  pass  through  small  slit-like  openings  in  the  muscular  coat, 
which  may  contract  around  them  and  prevent  return  of  the 
blood,  all  tend  to  produce  dilatation  of  the  veins.  These  en- 
larged veins  project  into  the  lumen  of  the  bowel,  and,  being 
continually  exposed  to  irritation  and  injury,  soon  become 
ulcerated.  Owing  to  the  relation  of  the  superior  hemorrhoidal 
vein  to  the  portal  system,  obstructive  disease  of  the  liver  usu- 
ally causes  congestion  and  ulceration  of  the  veins  of  the  hemor- 
rhoidal plexus.  Constipation,  fecal  impaction,  foreign  bodies, 
retroverted  uterus,  enlarged  prostate,  and  other  conditions 
which  interfere  with  the  circulation  are  frequent  causes  of  this 
form  of  ulceration. 


330  DISEASES  OF  THE  EECTUM  AND  ANUS 

Hemorrhoidal  ITlcers  may  follow  direct  injury  to  the  en- 
larged vessels  during  defecation,  or  by  some  hard  substance 
in  the  feces,  or  by  too  frequent  handHng  when  the  piles  pro- 
trude. Again,  a  dilated  vein  may.  rupture  and  a  clot  form  in 
the  tissues,  thus  producing  an  ulcer  from  irritation  and  infec- 
tion. Depending  upon  irritation  and  infection,  varicose  ulcers 
may  be  large  or  small  and  superficial  or  sufficiently  deep  to 
perforate  the  bowel  and  cause  abscess  and  fistula.  When  the 
hemorrhoids  protrude  and  become  strangulated  by  the  sphinc- 
ter-muscle, they  may  slough  off,  leaving  ulcers  of  considerable 
size.    Healing  of  the  latter  results  in  a  spontaneous  cure  of  the 


Fig.  100.— Ulceration  of  the  Rectum  Caused  by  Diphtheritic  Inflammation 
(Rectum  Turned  Inside  Out). 

pile,  but  sufficient  scar-tissue  may  be  left  to  produce  partial  or 
complete  stricture. 

Unusual  Forms  of  rectal  ulceration  sometimes  encountered 
in  the  ano-rectal  region  are  those  due  to  inflammation  of 
Bartholin's  glands,  diphtheritic  inflammation,  actinomycosis, 
and  leprosy. 

Poelchen  is  of  the  opinion  that  inflammation  and  suppura- 
tion of  Bartholin's  glands  not  infrequently  lead  to  perforation 
and  ulceration  of  the  rectum  and  the  formation  of  recto- 
vaginal fistula.  Like  other  parts  of  the  alimentary  canal,  the 
rectum  is  subject  to  diphtheritic  inflammation,  which,  however, 
is  of  very  rare  occurrence  in  this  region.  It  may  be  followed 
by  extensive  sloughing,  and  when  this  occurs  death  speedily 
ensues  from  sepsis  or  exhaustion.     The  accompanying  illus- 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  331 

tration  (Fig.  100)  is  from  a  photograph  of  a  post-mortem 
specimen  of  diphtheritic  ulceration  of  the  rectum  in  a  child, 
18  months  old,  taken  for  the  author  by  Dr.  Pisek. 

Actinomycosis  is  exceedingly  rare  in  the  rectal  region. 
Poncet,  the  leading  authority  on  this  disease,  knows  of  but 
eight  cases  of  its  occurrence  in  this  locality.  The  disease  may 
have  its  site  primarily  in  the  rectum  or  perirectal  tissues. 
When  actinomycosis  originates  in  the  intestine,  it  begins  by 
the  formation  of  nodular  granulomatous  deposits  in  the  mu- 
cosa and  submucosa;  these  contain  the  specific  fungi,  and 
presently  break  down  and  ulcerate.  The  process  may  extend 
to  the  peritoneum,  retroperitoneal  tissues,  or  adjacent  organs. 
"It  sometimes  causes  perforation  of  the  bowel,  resulting  in  fecal 
abscess  and  fistula"  (Ziegler).  According  to  Delbet,  the  char- 
acter of  actinomycosis  is  intermediate  between  an  inflamma- 
tory process  and  a  neoplasm ;  the  pathognomonic  sign  when  it 
is  evident  is  the  peculiar  hue  of  the  cutaneous  lesions,  which  varies 
from  violaceous  to  yellozvish  red,  interspersed  with  yellow  points. 
If  pus  is  produced,  the  peculiar  yellozvish  grains  which  occur 
therein  are  also  pathognomonic,  and  the  microscope  readily 
reveals  the  presence  of  the  ray-fungus. 

Leprosy  rarely  involves  the  ano-rectal  region  to  any  great 
extent,  but,  when  it  does,  the  characteristics  of  the  disease  are 
almost  the  same  as  in  other  parts  of  the  body.  Davis,  of 
Albany,  N.  Y.,  at  the  meeting  of  the  New  York  State  Medical 
Society,  in  January,  1901,  exhibited  a  photograph  of  a  case 
showing  the  lesions  of  leprosy  involving  the  buttocks  for  some 
distance  about  the  anus. 

SYMPTOMS 

The  more  prominent  symptoms  of  rectal  ulceration  are : — 

1.  Diarrhea.  4.  Discharges    of   pus   and 

2.  Pain.  mucus. 

3.  Hemorrhage.  5.  Pruritus. 

Diarrhea.  —  Rectal  ulceration  never  becomes  extensive 
without  causing  diarrhea  to  a  greater  or  less  degree.  Usually 
this  is  the  most  prominent  symptom;  the  patient  comes  to  be 
treated  for  it,  not  knowing  that  this  symptom  is  caused  by  the 
ulceration.  The  stools  may  vary  in  number  from  three  to 
twenty  daily;  they  are  accompanied  by  great  straining  and 


332  DISEASES  OF  THE  RECTUM  AND  ANUS 

tenesmus,  which  are  very  exhausting  and  cause  the  patient  to 
lose  rapidly  in  weight.  The  frequent  dejections  result  from 
contact  of  the  feces  with  the  exposed  nerve-filaments,  which 
excites  increased  peristalsis.  In  many  respects  the  symptoms 
resemble  those  of  dysentery,  for  which  it  has  been  mistaken. 

Pain. — Pain  caused  by  ulceration  was  referred  to  in  the 
chapter  on  the  general  symptomatology  of  rectal  disease,  but 
not  considered  in  detail.  Persons  suffering  from  ulceration 
may  have  but  little  or  a  very  great  amount  of  pain.  It  is  a 
common  thing  for  those  suffering  from  extensive  ulceration 
not  to  complain  of  pain,  especially  if  the  ulceration  is  situated 
high  up  in  the  rectum.  In  others,  where  the  ulceration  is  situ- 
ated lozv  down  near  the  anal  margin,  the  suffering  may  be  very 
intense,  though  the  ulcer  is  quite  small.  It  appears  that  the 
sensibility  varies  in  different  portions  of  the  rectum,  the  upper 
part  being  much  less  sensitive  than  the  lower.  In  fact,  the 
sensibility  increases  from  above  downzvard.  This,  together  with 
sphincteralgia,  explains  why  pain  is  so  great  in  an  ulcer  situ- 
ated at  the  anal  margin,  when  the  lesion  is  small  and  out  of 
all  proportion  to  the  amount  of  suffering. 

The  pain  of  ulceration  may  be  constant  or  intermittent ;  it 
is  usually  most  severe  during  and  immediately  after  stool.  In 
the  intervals  of  defecation  there  is  a  dull  aching,  which  may 
be  confined  to  the  rectum  or  extend  up  the  back  or  down  the 
limbs;  indeed,  the  reflex  symptoms  in  cases  of  ulceration  are 
many,  and  sometimes  so  marked  as  to  arouse  suspicion  of  a 
diseased  condition  of  the  bladder,  prostate,  uterus,  tubes,  or 
ovaries.  In  one  case  the  author  located  and  cured  a  rectal 
ulcer  which  caused  constant  pain  in  the  pelvis  for  the  relief  of 
which  both  ovaries  had  been  removed  without  the  slightest 
benefit.  From  this  and  other  cases  which  he  has  treated  it 
would  appear  that  the  uterus,  tubes  and  ovaries,  bladder,  or 
prostate  are  not  responsible  for  all  the  pains  produced  in  the 
pelvis ;  on  the  contrary,  idceration  of  the  rectum  not  infrequently 
plays  an  important  part,  and,  when  pelvic  pains  are  present 
which  cannot  be  accounted  for  in  any  other  way,  this  condition 
should  be  carefully  searched  for. 

Hemorrhage. — Hemorrhage  is  always  present  in  a  greater 
or  less  degree,  depending  upon  the  location  and  extent  of  the 
ulceration.  In  one  it  may  be  so  slight  that  the  discharges  are 
only  tinged  with  blood  or,  perhaps,  a  faint  streak  may  be  seen 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  333 

on  one  side  of  the  fecal  mass.  In  another  case,  when  the 
ulceration  has  eaten  deeply  into  the  tissues  and  attacked  some 
large  artery  or  vein,  the  bleeding  may  be  very  profuse.  Under 
these  circumstances  large  quantities  of  blood  may  be  lost  be- 
fore the  hemorrhage  ceases  or  can  be  arrested.  The  writer 
has  on  several  occasions  seen  hemorrhages  occur  to  such  an 
extent  that  the  patient  fainted  from  the  loss  of  blood;  others 
h'ave  reported  cases  that  terminated  fatally  as  a  result  of  such 
hemorrhages.  Ordinarily  there  will  be  more  or  less  bleeding 
after  stool,  because  the  passage  of  feces  over  the  raw  surface 
scrapes  off  any  little  plug  that  might  have  occupied  the  rent 
in  the  vessel,  and  thus  starts  bleeding  anew.  When  the  blood 
becomes  mixed  with  the  contents  of  the  rectum,  it  forms  a 
dark-brown,  semisolid  mass,  which  closely  resembles  compact 
coffee-grounds. 

Discharges.  —  Besides  blood,  there  are  discharges  of  pus 
and  mucus  in  varying  quantities.  When  the  ulcers  are  small 
the  discharge  is  slight,  but  increases  in  proportion  as  ulcera- 
tion extends.  The  discharge  is  sticky,  reddish  in  color,  of  the 
consistence  of  pus,  with  here  and  there  a  fragment  of  necrosed 
tissue,  and  constantly  oozes  out  at  the  anus,  the  margins  of 
which  become  glued  together. 

Itching. — -In  cases  of  long  standing  there  will  almost  in- 
variably be  pruritus  about  the  anal  margin.  This  may  extend 
in  any  direction,  until  many  deep  fissures  are  to  be  seen.  This 
condition  is  produced  by  the  irritating  discharges  that  are  con- 
stantly oozing  out,  and  it  usually  subsides  when  the  ulceration 
has  been  cured. 

When  the  ulceration  is  extensive  and  chronic,  the  patient 
is  subject  to  attacks  of  peritonitis,  which  may  cause  more  or 
less  extensive  intestinal  adhesions.  This  condition  has  been 
demonstrated  repeatedly  on  the  post-mortem  table.  In  the 
absence  of  free  exit  for  the  discharge  the  latter  will  burrow 
and  form  abscess  and  fistula. 

If  the  parts  are  not  cleansed,  but  are  permitted  to  remain 
constantly  moist,  hypertrophic  changes  may  occur  in  the  pa- 
pillae, resulting  in  the  formation  of  cauliflower-like  excrescences. 
Where  ulceration  is  extensive,  a  certain  amount  of  contraction 
unavoidably  follows  as  healing  takes  place.  As  the  ulceration 
encroaches  upon  the  anus,  both  sphincters  may  be  destroyed ; 
the  anus  becomes  patulous  and  surrounded  by  a  broad,  dark 


334  DISEASES  OF  THE  RECTUM  AND  ANUS 

ring,  with  several  club-shaped  tags  of  skin  hanging  about  the 
margins.  These  tags  of  discolored  skin  and  the  patulous  con- 
dition of  the  sphincter  are  always  indicative  of  serious  rectal 
disease.  Rectal  ulcers  of  the  perforating  variety  may  cause 
the  formation  of  a  recto-vesieai  or  recto-urethral  fistula. 

DIAGNOSIS 

The  diagnosis  of  rectal  ulceration  is,  in  most  cases,  easily 
made  when  a  correct  history  can  be  obtained  and  a  careful 
examination  has  been  made.  It  is  much  more  difficult,  how- 
ever, to  determine  the  character  of  the  ulceration. 

Syphilitic  and  chancroidal  ulcers  are  usually  elongated  and 
lissure-like,  especially  in  old  cases.  Tubercular  ulceration  is 
characterized  by  its  tendency  to  extend,  the  sharply-defined, 
undermined  edges  of  the  ulcers,  the  presence  of  miliary  tuber- 


Fig.  101.— Kelsey's  Rectal  Retractor. 


cles  in  and  around  the  lesions,  and  the  detection  of  tubercle 
bacilli  in  the  tissues  and  discharges.  In  malignant  ulceration 
the  ulcers  are  usually  extensive  and  very  deep,  extremely  pain- 
ful, and  secondary  to  the  breaking  down  of  indurated  deposits. 

When  any  doubt  exists  as  to  the  number,  size,  and  loca- 
tion of  rectal  ulcers,  these  points  can  be  cleared  up  by  closely 
inspecting  the  anus  and  rectum  by  means  of  the  finger,  re- 
tractor (Fig.  101),  speculum,  or  proctoscope.  Some  idea  of 
the  location  of  the  ulcer  may  be  had  from  the  character  of  the 
pain.  If  situated  in  the  upper  rectum,  there  is  but  little  pain ; 
but,  if  located  low  down  or  within  the  grasp  of  the  sphincter, 
pain  is  intense. 

PROGNOSIS 

Many  practitioners  consider  rectal  ulceration  a  trivial 
atTection  and  easy  to  cure.     It  is  true  that  traumatic  ulceration 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  335 

will,  in  the  majority  of  cases,  yield  promptly  to  simple  treat-, 
ment,  but  when  the  ulcers  are  chronic  and  of  tubercular,  syph- 
ilitic, malignant,  or  dysenteric  origin,  they  frequently  resist  all 
treatment  and  go  from  bad  to  worse  until  stricture  of  the  bowel 
is  produced,  perforation  occurs,  or  death  results  from  the  ex- 
haustion induced  by  depleting  hemorrhages  or  chronic  diar- 
rhea. It  is  well  to  make  a  guarded  prognosis  in  these  cases, 
because  it  requires  a  much  longer  time  to  effect  a  cure  than 
is  generally  supposed.  It  has  been  the  author's  custom  to  in- 
form this  class  of  patients  that  their  suffering  will  be  diminished 
from  the  beginning  of  the  treatment,  but  that  it  may  take  sev- 
eral weeks  or  months  entirely  to  heal  the  ulceration,  and,  further- 
more, that  in  extensive  cases  more  or  less  narrowing  of  the  bowel 
may  result. 

TREATMENT 

The  line  of  treatment  in  rectal  ulceration  depends  upon 
the  patient's  general  health  and  the  cause,  number,  size,  and 
character  of  the  ulcers.  When  the  patient  is  debilitated,  nour- 
ishing diet  and  tonics  should  be  prescribed.  When  a  tuber- 
cular or  syphilitic  diathesis  exists,  antitubercular  or  constitu- 
tional treatment  is  indicated ;  in  ulceration  due  to  dysentery, 
ipecacuanha  —  administered  in  large  doses  —  gives  the  best 
results. 

The  local  treatment  of  rectal  ulceration  is : — ■ 
1.  Non-operative.  2.   Surgical. 

NON=OPERATIVE   TREATMENT 

The  most  important  features  in  non-operative  treatment  are 
to  secure  daily  semisolid  stools,  protect  the  ulcers  as  far  as  pos- 
sible from  the  irritation  of  the  feces,  keep  the  patient  in  bed, 
regulate  the  diet,  and  make  applications  or  injections  of  soothing, 
stimulating,  escharotic,  or  cauterizing  remedies. 

When  there  is  a  tendency  to  constipation  and  fecal  impac- 
tion, salts,  cascara  sagrada,  compound  licorice-powder  in  small 
doses,  Carabaha,  Hunyadi,  or  other  reputable  mineral  water 
should  be  given  in  sufficient  doses  to  secure  regular,  semisolid 
stools.  In  most  cases,  however,  the  patient  complains  of  fre- 
quent stools,  and  in  order  to  overcome  the  diarrhea  and  tenes- 
mus it  is  necessary  to  prescribe  such  remedies  as  tannic  acid, 
gallic  acid,   and  preparations  containing  starch,  bismuth,   mag- 


336 


DISEASES  OF  THE  RECTUM  AND  ANUS 


nesia,  and  chalk.  When  pain  is  distressing,  opiates  may  be 
given,  but  with  caution,  because  of  the  danger  of  the  patient 
forming  the  drug  habit. 

Rest  in  the  recumbent  position  not  only  overcomes  the 
irritation  induced  by  exercise,  but  prevents  congestion  of  the 
rectum  which  occurs  in  the  upright  position  and  removes  the 
weight  of  the  pelvic  organs  from  the  affected  parts.     In  rectal 


ig.  102.— Sims's  Rectal  Irrigator  and  Draining-tube. 


ulceration  rest  is  as  essential  as  is  elevation  and  support  in  the 
treatment  of  varicose  conditions  of  the  lower  extremities. 

The  Diet  in  these  cases  should  be  simple,  nourishing,  non- 
irritating,  and,  as  far  as  practicable,  liquid  and  semisolid.  Some 
patients  do  well  on  an  exclusive  milk  diet.  Highly-seasoned 
foods,  pastries,  fried  meats  and  vegetables  cooked  in  grease, 


Fig.  103.— Insufflator. 

alcoholic  stimulants,  and  ice-cold  and  carbonated  beverages 
should  be  prohibited. 

Local  Applications  to  the  ulcers  should  always  be  preceded 
by  emptying  the  rectum  and  thoroughly  cleansing  the  sores, 
by  irrigation  of  the  bowel  (Fig.  102)  with  sterile  water,  soap- 
suds, or  weak  antiseptic  solutions  of  carbolic  or  boric  acid, 
mercury  bichloride,  or  potassium  permanganate.  The  topic 
applications  which,  from  their  stimulating  or  astringent  effects, 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE 


337 


have  given  the  best  results  in  heahng  the  ulcers  are  silver 
nitrate,  ichthyol,  balsam  of  Peru,  alum,  silver  lactate  or  citrate, 
and  zinc  sulphate ;  the  strength  of  these  solutions  has  been 
given  in  the  chapter  on  painful  ulcer.  The  author  prefers 
solutions,  but  in  many  cases  dusting-powders  of  lead,  zinc, 
alum,  calomel;  bismuth,  subnitrate,  salicylate,  or  subiodide; 
iodoform,  orthoform,  or  zinc  stearate,  either  alone  or  in  com- 
bination, will  be  found  useful;  they  may  be  applied  by  means 


Fig.  104.— Allingham's  Ointment  Applicator. 

of  the  insufflator  (Fig.  103)  or  on  cotton  upon  the  end  of  an 
applicator.  The  greatest  objection  to  powders  is  that  they 
often  cake  and  produce  more  or  less  irritation. 

Some  patients  suffer  less  and  seem  to  progress  more  rap- 
idly when  the  above  remedies  are  used  in  form  of  an  ointment. 
In  this  form  they  may  be  applied  directly  or  with  Allingham's 
ointment  applicator  (Fig.  104),  when  the  ulcers  are  low  down ; 
or  by  means  of  the  author's  ointment  syringe  (Fig.  105), 
which    is    suitable    for    applications    in    the    lower    or    upper 


Fig.  105. — Author's  Recto-colonic  Ointment  Syringe. 


rectum  or  sigmoid  colon.  When  the  ulcers  are  very  sensitive 
and  cause  much  pain,  suffering  may  be  relieved  by  eucaine, 
cocaine  or  belladonna  and  opiates,  either  in  ointment  or  sup- 
positories; the  ointment  form  is  best  because  the  suppositories 
are  usually  either  so  soft  that  their  introduction  is  difficult  or 
so  firm  that  they  press  upon  the  ulcer  and  irritate  the  sphincter. 
Cauterization  with  potential  silver,  copper  sulphate,  or  the 
actual  cautery  should  be  resorted  to  when  the  ulcers  have  be- 
come chronic  or  refuse  to  heal  under  stimulating  treatment. 


338  DISEASES  OF  THE  RECTUM  AND  ANUS 

Before  the  application  of  the  ■  cautery  the  ulcers  should  be 
eucainized  or  cocainized. 

When  the  ulceration  is  obstinate  and  located  in  the  upper 
rectum  or  colon  where  direct  applications  cannot  be  made,  it 
is  necessary  to  give  high  injections  through  a  long,  soft-rubber 
colon-tube.  The  most  reliable  remedies  for  these  high  injec- 
tions are  silver  nitrate,  20  to  40  grains  (1.3  to  2.8  grams),  or 
a  combination  of  fluid  extract  of  krameria,  2  ounces  (60 
grams) ;  biborate  of  soda,  1  drachm  (4  grams) ;  and  distilled 
water,  1  pint  (500  cubic  centimeters).  Another  soothing  and 
effective  combination  which  has  proven  very  satisfactory  in 
the  author's  practice  consists  of  iodoform,  1  drachm  (4  grams)  ; 
bismuth  subnitrate,  ^/a  ounce  (15  grams) ;  and  olive-oil,  1  pint 
(480  cubic  centimeters) ;  4  ounces  (120  grams)  of  this  emulsion 
should  be  injected  just  before  retiring,  and  retained  as  long  as 
possible. 

SURGICAL  TREATMENT 

The  surgical  treatment  of  rectal  ulceration  requires  to  be 
changed  to  suit  the  case,  and  should  not  be  resorted  to  except 
where  palliative  measures  have  failed.  In  most  instances 
curettage,  followed  by  stimulating  applications,  will  suffice ;  but, 
in  other  cases,  especially  where  the  ulcers  are  located  within 
the  grasp  of  the  sphincter  and  cause  great  pain,  the  sphincter 
should  be  thoroughly  divulsed  before  curetting,  and  in  some 
cases  it  is  necessary  to  incise  the  muscle.  In  very  rare  instances 
an  ulcer  may  be  excised  by  an  elHptic  incision  and  the  wound 
closed  with  catgut;  but  primary  union  is  very  difficult  to 
obtain,  because  of  infection  and  the  irritation  incident  to  defe- 
cation. 

In  cases  of  long  standing,  in  which  the  ulceration  is  ex- 
tensive, has  resisted  all  other  treatment,  and  the  patient  is 
rapidly  becoming  exhausted  from  pain  and  frequent  stools,  a 
temporary  left  inguinal  colostomy  should  be  made  as  soon  as 
possible.  The  teachings  of  surgeons  who  maintain  that  the 
rectum  becomes  atrophied  shortly  after  the  establishment  of  an 
artificial  anus  and  cannot  perform  its  function  have  been 
proven  to  be  erroneous.  The  author  some  years  ago  performed 
left  inguinal  colostomy  on  a  young  woman  suffering  from  ex- 
tensive ulceration  which  refused  to  heal  under  less  radical 
treatment.  In  this  instance  the  feces  were  discharged  through 
the  opening  in  the  groin  for  more  than  three  years,  when  it 


NON-:\IALIGNANT  ULCERATION  AND  ESTHIOMENE 


339 


was  closed;  from  that  time  on  the  feces  were  discharged 
through  the  rectum,  the  function  of  which  was  in  no  way  im- 
paired. The  author  has  in  several  cases  succeeded  in  curing 
ulceration  by  the  establishment  of  such  an  artificial  anus,  which 
removes  the  irritation  of  the  feces  and  allows  the  ulcers  to  be 
kept  clean  and  treated  by  direct  applications  and  irrigations 
both  from  above  and  below.  The  technic  of  this  operation  is 
fully  described  in  the  chapter  on  colostomy. 

ESTHIOMENE 

Esthiomene^  (lupus  exedens)  is  a  rare  disease  character- 
ized by  extensive   superficial  ulcerations,   involving  the   ano- 


Fig.  106— Esthiomene,  Vegetating  Variety  (Ano-vulvar  Region). 

vulvar  region,  accompanied  by  hypertrophy  and  marked  de- 
formity of  these  parts  (see  Dr.  Allen's  case,  Fig.  106). 

ETIOLOGY   AND   PATHOLOGY 

Ouenu  and  Hartmann,  who  have  made  the  most  exhaust- 
ive investigations  of  ano-rectal  tuberculosis,  hold  that  primary 
lupus  may  rarely  occur  in  this  region,  and  that  the  so-called 
ano-vulvar  esthiomene  is  the  lupoid  ulcers  of  AlHngham.  They 
know  of  but  two  cases  of  lupus  limited  to  the  anus,  both  of 
which  had  their  origin  at  the  orifice  of  a  fistula.  Huguier,  in 
1848,  under  the  title  "Esthiomene  of  the  Vulvo-anal  Region," 
reported  nine  cases  of  deformity  of  this  region  due  to  extensive 
ulcerations.     Since  that  time  other  cases  have  been  reported 

^ia-diofxevT],  eating. 


340  DISEASES  OF  THE  RECTUM  AND  ANUS 

under  the  same  title,  but  later  investigators,  especially  Peck- 
ham,^  have  shown  that  the  ulceration  causing  the  deformity  in 
these  cases  is  due  to  a  variety  of  diseases:  i.e.,  lupus,  tubercu- 
losis, syphilis,  epithelioma.  Taylor  maintains  that  esthiomene 
is  not  an  independent  disease,  and  that  the  name  should  be 
discarded ;  he  asserts  that  it  is  an  aggravated  condition  of  other 
ulcerative  diseases  of  the  vulvo-anal  region,  such  as  tuberculo- 
sis, lupus,  chancroids,  and  syphilis,  which  have  been  neglected, 
and  that  the  parts  have  become  deformed  because  of  the  trau- 
matism and  the  chronic  inflammation  which  accompany  such 
ulcerations. 

Peckham  has  suggested  that  the  various  deforming  dis- 
eases heretofore  described  as  esthiomene  should  be  designated 
"hypei'trophic  vulvar  idcerations,"  and  that,  according  to  the 
diagnosis,  they  should  be  described  as  syphilitic,  scrofulous, 
lupoid,  or  tuberculous.  Of  the  thirty-three  cases  of  ulcerative 
lesions  of  the  vulvo-anal  region  tabulated  by  the  latter  author- 
ity, twelve  gave  a  direct  history  of  syphiHs,  while  fourteen 
might  have  had  it.  According  to  this  same  authority,  this 
shows  that  syphilis  plays  the  most  important  role,  and,  hence, 
in  the  majority  of  these  cases  a  phagedenic  syphilide,  rather 
than  lupus,  must  be  dealt  with. 

On  the  part  of  authorities  best  qualified  to  speak,  includ- 
ing Quenu  and  Hartmann,  and  Delbet,  there  is  now  a  general 
tendency  to  assign  ano-perineal  tuhercidosis,  which  may  or  may 
not  become  lupoid  in  character,  or  lupus  as  the  cause  of  the 
deforming  hypertrophic  ulcerative  processes  which  have  in  the 
past  been  known  as  esthiomene. 

It  is  not  difBcult  to  understand  how  ano-perineal  tubercu- 
losis (Figs.  96  and  97)  may  be  encouraged  to  extend  and  per- 
haps assume  a  lupoid  character  because  of  frequent  infection 
from  feces,  stretching  of  the  parts  during  defecation,  irritation 
incident  to  coitus  and  from  uterine  and  vaginal  discharges, 
especially  in  prostitutes,  and  the  constant  irritation  of  the 
ulcers  while  walking,  riding,  etc. 

While  the  author  believes  in  the  tubercular  origin  of  most 
of  these  deforming  ulcerations,  he  is  confident  that  a  condition 
of  like  nature  may,  in  rare  instances,  be  induced  by  syphilitic 
or  chancroidal  ulcers  which  have  become  phagedenic. 

1  Dr.  Peckham  has  married  since  writing  her  article  on  esthiomene  an(l  is  now 
known  as  Dr.  Grace  Peckham  Murray. 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  341 

The  lesions  of  so-called  esthiomene  may  first  become 
manifest  at  the  anal  or  vulvar  margin  in  the  form  of  small, 
round,  rather  hard,  dark-reddish  nodules,  which  may  remain 
without  perceptible  change  for  a  considerable  time  or  imme- 
diately soften  and  break  down,  leaving  the  characteristic  ulcers, 
which  have  a  granular  base,  violet  hue,  irregular  and  slightly- 
elevated  indurated  edges,  and  exude  a  thin,  watery  sero-puru- 
lent  discharge.  In  time  other  small  nodules  appear  and  break 
down,  producing  multiple  ulcers,  which  may  coalesce  and  form 
one  extensive  ulcer  or  several  large  ulcers  separated  by  an 
apparently  sound  tissue.  These  ulcers  may  remain  superficial 
or  extend  deeply,  destroying  the  recto-vaginal  septum,  caus- 
ing abscess  and  fistula,  or  sometimes  resulting  in  perforation 
of  the  bowel  and  peritonitis.  Ulcerations  of  this  type  are 
chronic  and  slozvly  progressive,  and  when  not  radically  dealt 
with  eventually  result  in  partial  or  complete  destruction  of  the 
skin,  mucous  membrane,  and,  in  fact,  all  the  tissues  of  the 
ano-vulvar  region  (Fig.  106).  Owing  to  gradual  hypertrophy 
and  dense  elephantiasic  thickening  of  the  parts,  the  very 
marked  deformity  of  the  ano-vulvar  region  so  characteristic  of 
this  affection  follows.  Again,  the  ulcers  may  be  serpiginous, 
and,  while  extending  in  one  direction,  may  heal  in  another, 
leaving  delicate,  white  cicatrices  which  easily  break  down. 
Frequently  tubercle  bacilli  can  be  demonstrated  in  the  tissue 
and  discharges  from  these  ulcers,  especially  in  recent  cases; 
in  chronic  cases,  however,  where  the  elephantiasic  condition  so 
characteristic  of  this  affection  exists,  little  information  as  to 
the  nature  and  cause  of  the  disease  is  to  be  gained  from  micro- 
scopic examination.-  In  such  cases  Auspitz  was  unable  to  dif- 
ferentiate between  scrofula,  syphilis,  and  lupus. 

In  regard  to  the  histology  of  lupus  Peckham  says :  "Lupus 
itself  is  in  an  unsettled  state  beyond  that  it  is  a  proliferation 
of  embryonic  cells;  but  when  this  proliferation  originates  is  a 
matter  of  dispute.  Some  observers  remark  on  the  presence  of 
giant  cells,  but  they  are  not  always  seen.  The  microscope, 
then,  at  present  can  do  no  more  than  differentiate  these  ulcera- 
tive lesions  from  carcinoma." 

SYMPTOMS 

The  symptoms  of  esthiomene,  so  called,  are  characteristic 
of  the  affection.     The  pain  is  so  very  slight  that  it  is  out  of  all 


342  DISEASES  OF  THE  RECTUM  AND  ANUS 

proportion  to  the  extent  of  the  lesion.  Again,  the  general 
health  does  not  seem  to  be  affected  by  the  condition,  and  only 
in  exceptional  cases  are  the  patients  confined  to  the  house. 
Although  the  ulceration  is  very  extensive  and  may  exist  for 
several  years,  it  rarely  causes  death.  The  most  frequent  com- 
plications are  peritonitis,  pulmonary  tuberculosis,  fistula,  hem- 
orrhages, enlarged  inguinal  glands,  and  fatty  degeneration  of 
the  liver;  this  latter  condition  is  such  a  common  complication 
that  some  writers  maintain  that  it  is  always  present  in  esthio- 
mene. 

DIAGNOSIS 

The  diagnosis  in  these  cases  is  based  upon  the  violaceous 
color  of  the  ano-vulvar  region,  the  chronicity,  the  phagedenic  and 
other  characters  of  the  idceration,  and  the  deformed  condition 
of  the  parts.  It  may  be  mistaken  for  carcinoma,  but  can  be 
differentiated  from  the  latter  by  the  non-offensive  odor  of  the 
discharge,  slow  growth,  absence  of  cachexia,  and  the  fact  that 
it  causes  but  little  pain.  When  doubt  still  exists,  the  nature 
of  the  growth  will  be  revealed  by  microscopic  examination  of 
tissue. 

Rodent  TJlcer  is  a  disease  for  which  this  condition  has  also 
been  mistaken.  Rodent  ulcer,  however,  is  common  to  old  age, 
is  accompanied  by  much  more  pain,  and  is  not  marked  by  the 
elephantiasic  deformity  which  exists  in  esthiomene.  Again, 
rodent  ulcer  occurring  in  the  ano-vulvar  region  is  very  similar 
to  that  observed  in  other  parts  of  the  body. 

TREATMENT 

The  treatment  of  ulcerative  deformities  of  the  ano-vulvar 
region  known  as  esthiomene  is  uncertain  in  its  results.  It  is 
always  difficult  and  sometimes  impossible  to  check  the  progress 
of  the  disease.  Tonics  are  always  indicated,  and  antituber- 
cular  and  antisyphilitic  remedies  when  the  diagnosis  points  to 
tuberculosis  or  syphilis.  The  parts  should  be  kept  thoroughly 
cleansed  and  protected  from  irritation  by  suitable  dressings. 
Strong,  stimulating,  escharotic,  or  cauterizing  agents  should 
be  applied  to  the  ulcers  as  often  as  seems  necessary.  When 
these  agents  prove  ineffective,  the  ulcers  and  hypertrophied 
tissue  should  be  excised,  and,  after  bleeding  has  been  arrested, 
the  surfaces  of  the  Vv^ounds  should  be  cauterized  with  the 
Paquelin  cautery  in  order  to  destroy  every  vestige  of  the  dis- 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  343 

ease.  Peckham — who  has  made  a  close  analysis  of  nearly,  if 
not  quite,  all  of  these  cases  reported  and  described  as  esthi- 
omene  before  1890 — says  that  the  latter  method  of  dealing 
with  this  affection  is  the  most  reliable. 

The  treatment  of  rodent  ulcer  is  identic  with  that  of  so- 
called  esthiomene  and  epithehoma  elsewhere. 

To  illustrate  how  extensive  the  destruction  of  tissues  may 
be  in  lupus  of  the  vulvo-anal  region,  the  writer  will  give  a  brief 
abstract  of  a  case  reported  by  Dr.  Angus  McDonald. 

On  the  hips,  just  beyond  the  ischial  tuberosities,  were 
long  scars  of  healed  ulcers,  thin  and  bluish.  The  entire  ano- 
perineal  region  was  gone,  and  in  its  place  a  hollow  space  as 
big  as  a  fetal  head.  The  urethra  was  entire,  as  well  as  the 
mucous  membrane  between  it  and  the  cervix,  which  was 
healthy.  The  anus,  rectum,  and  the  vagina,  other  than  the 
anterior  portion,  were  gone ;  there  was  an  opening  by  a  tight 
aperture  behind  the  cervix.  The  patient  could  not  keep  clean, 
except  when  the  feces  were  liquid.  In  this  fearful  condition 
she  performed  her  household  duties.  Finally  the  ulceration 
extended  upward  into  the  pelvis,  leaving  the  bowel  hanging 
loose  for  some  distance  from  the  upper  level  of  the  ulceration, 
giving  it  the  appearance  of  a  torn  coat-sleeve.  After  several 
years'  suffering  she  died  of  diarrhea  and  exhaustion. 

ILLUSTRATIVE  CASES 
Case  XV.  TJlceration  of  the  Rectum  (Temporary  Colostomy;  Artificial 
Anus,  Closed  More  than  Three  Years  Later).— A  young  woman  applied  for 
treatment  for  rectal  trouble  which  proved  on  examination  to  be  an  extensive 
ulceration,  evidently  of  tubercular  origin.  Many  general  and  local  remedial 
agents  and  thorough  curettement"  had  been  previously  tried,  but  her  condition 
had  only  become  worse.  The  ulceration  had  extended  until  almost  the  entire 
rectum  was  involved.  Her  complexion  was  bad,  she  was  emaciated,  suffered 
from  chronic  diarrhea,  and  had  frequent  discharges  of  pus,  blood,  and  mucus. 
She  was  rarely  free  from  pain,  which  was  located  in  the  rectmn  and  reflected 
up  the  back  and  down  the  limbs.  Temporary  left  inguinal  colostomy  was 
advised,  readily  consented  to,  and  was  performed  soon  after.  From  the  time 
the  artificial  anus  was  established,  all  fecal  matter  passed  out  through  it; 
nothing  was  discharged  from  the  rectum  except  a  slight  amount  of  mucus.  A 
solution  of  alum,  1  drachm  (4  grams)  to  a  quart  (1  liter)  of  water,  was 
passed  into  the  rectum  through  the  anus  and  out  at  the  gi-oin,  night  and 
morning,  and  during  the  first  few  weeks  the  ulcerated  surface  was  touched 
up  three  times  weekly  with  a  solution  of  silver  nitrate,  20  grains  (1.2  grams) 
to  the  ounce  (30  cubic  centimeters).  In  addition  she  was  given  antitubereular 
treatment. 


344  DISEASES  OF  THE  RECTUM  AND  ANUS 

Within  six  months  from  the  time  of  operation  all  annoying  symptoms 
had  disappeared  and  she  said  she  felt  perfectly  well.  During  the  next  three 
years  she  reported  every  few  weeks,  all  of  which  time  the  best  of  health  was 
enjoyed.  She  gained  considerably  in  weight,  and  earned  her  own  living  as 
waitress.  She  usually  had  one  free  action  daily  before  breakfast  and  at  other 
times  was  not  bothered  with  the  frequent  discharge  of  feces  as  occasion- 
ally occurs  after  colostomy.  A  little  over  three  years  after  the  operation 
she  became  engaged,  and  desired  me  to  close  the  opening.  Examination 
showed  that  the  ulceration  had  entirely  healed  and  there  was  no  indication 
of  stricture.  A  No.  10  Wales  bougie  (extra  length)  was  passed  in  through 
the  anus  and  out  through  the  opening  in  the  groin  without  difficulty.  She 
was  placed  in  the  hospital  and  prepared  and  I  operated  two  days  later. 

An  incision  was  made  at  the  junction  of  the  skin  and  mucous  membrane 
and  the  gut  carefully  dissected  from  its  attachments.  Owing  to  the  spur, 
the  ends  of  the  gut  were  firmly  adherent  to  each  other,  showing  the  superiority 
of  this  method  of  operating  over  that  of  simply  stitching  the  upper  edge 
of  the  sigmoid  to  the  parietes;  the  latter  permits  fecal  matter  to  pass  out  of 
the  opening  in  the  groin  and  also  through  the  rectum.  The  adherent  por- 
tions were  excised,  a  purse-string  suture  thrown  around  each  end  of  the  gut, 
and  a  Murphy  button  inserted  and  locked.  The  sutures  were  tied  and  the 
intestine  dropped  back  into  the  abdominal  cavity.  The  peritoneum,  muscles, 
and  integument  were  brought  together  separately  with  catgut  and  a  dry 
dressing  applied.  Primary  union  occurred.  The  button  passed  on  the  tenth 
day.    Recovery  was  uninterrupted. 

She  was  under  observation  for  a  year  following  the  operation,  and  there 
was  never  any  indication  of  stricture  or  any  sign  of  a  return  of  the  ulceration, 
nor  were  there  any  signs  of  atrophy  of  the  bowel  from  non-use,  and  her 
evacuations  were  normal  in  size  and  frequency.  There  are  few,  if  any,  cases 
on  record  where  an  artificial  anus  had  existed  so  long  and  been  closed  by  an 
end-to-end  anastomosis. 

Case  XVI.  Ulceration  of  the  Rectum  (Curettage  and  Incision).— A 
banker,  aged  41,  a  slender  man  of  pallid  countenance,  consulted  me  in  the 
latter  part  of  December  for  the  relief  of  rectal  trouble.  He  experienced 
considerable  pain  during  defecation,  and  at  times  there  was  more  or  less 
bleeding  and  always  some  pus.  When  on  his  feet  he  sufi'ered  intense  pain 
almost  constantly;  now  and  then  it  would  be  reflected  up  the  back  and  down 
the  legs.  Of  late  he  had  been  much  annoyed  by  an  unpleasant  sensation  in 
the  lower  portion  of  the  rectum,  as  if  the  bowel  were  going  to  act.  The 
stools  were  frequent  and  accompanied  by  griping  and  tenesmus.  His  general 
health  was  carefully  examined  into  and  found  to  be  all  that  could  be  desired. 
The  sphincter  being  very  tight,  an  anesthetic  was  advised,  so  that  a  thorough 
examination  might  be  made.  The  author's  operating  speculum  was  inserted 
well  up  the  bowel  after  the  sphincter  had  been  divulsed.  By  the  aid  of  a 
good  light  an  ulcer  as  large  as  a  silver  half-dollar  was  located  on  the  pos- 
terior  wall  of  the  rectum,  a  little  to  the  right  of  the  median  line,  and  two 
and  one-half  inches  (6.4  centimeters)  above  the  anus;  its  edges  were  rounded, 
raised,  and  very  hard,  all  of  which  demonstrated  that  it  had  existed  for  a 
considerable  time.  On  either  side  of  it  were  two  white,  polypoid  growths 
about  half  an  inch  (1.3  centimeters)  long  (Plate  XVIII).     The  mucous  mem- 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  345 

brane  below  the  ulcer  and  the  skin  about  the  anus  were  somewhat  excoriated, 
because  of  the  acrid  discharge  that  was  constantly  passing  over  them. 

Treatment.  —  The  ulcer  was  curetted  and  incised  down  through  the 
sphincter.  The  bowel  was  irrigated  with  a  solution  of  carbolic  acid,  and  a 
piece  of  gauze  inserted  to  insure  drainage.  The  patient  was  then  placed  in 
bed  and  surrounded  by  hot  bottles.  Thirty-six  hours  afterward  the  gauze  was 
removed,  the  rectum  irrigated,  and  the  ulcer  dusted  over  with  calomel,  which, 
by  the  way,  is  a  valuable  remedial  agent  in  exciting  healthy  granulations  in 
almost  any  chronic  sore.  A  fluid  and  semisolid  diet — which  consisted  prin- 
cipally of  milk,  soft-boiled  eggs,  and  strong  soups — was  ordered.  The  bowels 
were  moved  every  second  day  by  the  aid  of  mild  cathartic  mineral  waters.  He 
was  not  allowed  to  get  out  of  bed  or  sit  up  for  three  weeks.  During  this 
time  the  ulcer  was  cleansed,  and  a  solution  of  silver,  the  balsam  of  Peru,  or 
calomel  applied  every  other  day.  By  this  time  the  diarrhea  had  stopped,  pain 
had  ceased,  and  he  had  gained  ten  pounds  in  weight.  The  local  applica- 
tions were  continued  for  three  weeks  longer,  at  the  end  of  which  time  the 
ulcer  had  entirely  healed.  He  was  then  discharged,  with  instructions  to 
return  to  the  city  immediately  should  he  ever  feel  any  uneasiness  about  the 
rectum. 

Case  XVII.  Ulceration  of  the  Rectum  (Cauterization  with  Nitric  Acid). 
— I  was  requested  to  visit  a  young  lady,  of  exceedingly  nervous  temperament, 
suffering  from  some  rectal  disorder.  She  had  been  very  despondent  of  late, 
and  had  frequently  remarked  that  if  relief  was  not  soon  obtained  she  would 
commit  suicide.  Six  months  previously  she  had  had  a  diarrhea,  which  lasted 
for  three  weeks,  when  suddenly  it  ceased  and  she  became  markedly  consti- 
pated. Up  to  this  time  she  had  no  pain,  except  the  tenesmus  that  accom- 
panied the  frequent  stools ;  recently,  however,  pain  was  seldom  absent.  When 
asked  to  locate  the  pain,  she  placed  her  hand  over  the  coccyx  and  sacrum, 
and  said  it  was  there  most  of  the  time,  but  now  and  then  over  the  ovaries. 
She  suffered  most,  however,  during  and  for  about  one  hour  after  defecation. 
The  pain  was  so  severe  at  times  that  she  almost  had  convulsions.  She  men- 
struated regularly,  and  there  was  no  indication  of  bladder  or  kidney  trouble. 
She  finally  consented  to  a  rectal  examination,  provided  I  would  give  her 
chloroform  and  do  what  was  required  at  the  same  time. 

Examination  revealed  three  iilcers,  each  about  the  size  of  a  silver  dime, 
at  and  above  the  upper  edge  of  the  internal  sphincter.  They  were  highly 
inflamed,  as  was  also  the  surrounding  mucosa.  The  sphincter-muscles  were 
divulsed  and  the  ulcers  carefully  cauterized  with  nitric  acid.  Since  the  edges 
of  the  ulcers  were  not  thickened  or  indurated,  and  the  muscles  were  not 
hypertrophied,  it  was  not  thought  advisable  to  incise  either.  She  was  kept 
in  the  recumbent  position,  the  diet  restricted  to  liquids  and  semisolid  foods, 
and  the  boAvels  moved  gently  every  other  day.  In  the  meantime  the  rectum 
was  irrigated  daily  with  carbolized  water,  and  a  mild  astringent  was  applied 
to  the  ulcer  every  other  day.  This  plan  of  treatment  was  continued  for  only 
two  weeks,  when  the  ulcers  were  completely  healed  and  all  the  local  symp- 
toms had  disappeared.  Three  months  after  she  was  discharged  she  wrote  that 
she  was  perfectly  well. 

Case  XVIII.  Tubercular  "Ulceration  (Curettage). — A  lady,  aged  31,  had 
inherited  a  phthisic  constitution  fi-om  her  mother,  and  had  always  been  very 


346  DISE3:SES  OF  THE  RECTUM  AND  ANUS 

delicate.  One  year  previous  to  the  time  I  saw  her  she  "caught  a  cold,"  and 
had  been  bothered  with  a  very  annoying  cough  ever  since.  She  had  night- 
sweats,  which  weakened  her  very  much.  In  addition  to  this  she  was  suffering 
from  a  rectal  trouble  which  caused  much  pain,  and  she  had  frequent  stools 
mixed  with  a  thin,  glairy,  offensive  pus. 

Examination  revealed  a  patulous  anus.  The  speculum  was  inserted  with- 
out the  slightest  pain,  and  a  deep  ulcer  with  irregular  edges  was  located  just 
within  the  external  sphincter,  which  was  almost  eaten  through.  The  latter, 
in  part,  accounted  for  the  patulous  appearance  of  the  anus. 

Treatment. — On  account  of  the  lung  complication  it  was  deemed  advisable 
not  to  give  an  anesthetic,  but  to  cocainize  the  parts,  and  curette  and  apply 
potential  silver  to  the  ulcer.  It  was  also  deemed  inadvisable  to  incise  the 
sphincter,  because  in  tubercular  subjects  cutting  is  liable  to  result  in  inconti- 
nence. Tonics  and  a  strong  diet  were  prescribed;  she  was  also  requested  to 
spend  most  of  her  time  in  the  open  air  and  sunshine.  This,  together  with  the 
local  application  of  mild  astringents,  constituted  the  treatment.  It  required 
nearly  three  months  for  the  ulcer  to  heal,  owing  to  the  debilitated  condition 
of  the  patient.  She  was  never  bothered  again  with  the  ulceration,  but  died, 
some  eighteen  months  after  she  left  the  hospital,  from  the  old  lung  trouble. 


LITERATURE  ON  NON-MALIGNANT  ULCERATION  OF  THE  RECTUM 


Cooke:    "Ulceration  of  the  Rectal  Pouch,"  Mathews's  Med.  Quart.,  vol.  iv,  p. 

227,  1897. 
Delbet:    "Ano-rectal  Tuberculosis,"  le  Dentu  and  Delbet's  "Treatise  on  Sur- 
gery," vol.  viii,  1889. 
Earle:     "Initial  Tuberculosis   of  the  Rectum,"  reprint  from  Baltimore  Med. 

Coll.  Alumni  Jour,  (date  not  given). 
Faure   and   Rieffel:     "Tuberculosis    of   the   Rectum   and   Anus,"    Duplay    and 

Reclus's  "Treatise  on  Surgery,"  vol.  vi  (second  edition),  1898. 
Foster:    "Non-malignant  Ulceration,"  Jour.  Med.  Science,  vol.  v,  p.  141,  1889. 
Fournier:    "Lesions  Tertiares  de  I'Anus  et  du  Rectum."     Paris,  1875. 
Freichs:    "Beitrage  zur  Lehre  von  der  Tuberculose."     Marburg,  1882. 
Gosselin:    "Des  retrecissements  Syphilitique  du  Rectum,"  Arch.  Gen.  de  Med., 

iv,  p.  567,  1854. 
Grode:    "The  Intestine  in  Tuberculosis,"  These.     Paris,  1888. 
Hahn:      "Zur    Behandlung    der    Syphilitischen    Mastdarm    Ulceration    durch 

Colotomie,"  Arch.  f.  Uin.  Cliir.,  p.  395,  1883. 
Huguier:    L'esthiomene,  Mem.  de  V Academic,  t.  xiv,  p.  508.    Paris,  1848. 
Mathews:    "Ulceration  of  the  Rectum,"  MatheiDs's  Med.  Quart.,  vol.  v,  p.  137, 

1898. 
McLarne:     "Secondary    Syphilitic    Ulcerations,"    Edinburgh    Clin,    and    Path. 

Jour.,  p.  625,  1883-84. 
Molliere:    "Maladies  du  Rectum  et  de  I'Anus,"  pp.  635,  679. 
Paget:    "Diflferential  Diagnosis  between  Syphilitic  and  Tubercular  Ulceration," 

Med.  Times  and  Gazette,  vol.  i,  p.  279,  1865. 
Poelchen:    Arch.  f.  'path.  Anat.  u.  Phys.,  vol.  cxxvii,  p.  189,  1892. 


NON-MALIGNANT  ULCERATION  AND  ESTHIOMENE  347 

Qugnu  and  Hartmann:    "Ano-rectal  Tuberculosis,"  "Surgery  of  the  Rectum," 

1895. 
Taylor:    "Syphilitic  Ulceration  of  the  Rectum,"  Jour.  Cutan.  and  Vener.  Dis., 

p.  424,  1886. 
Tuttle :    "Syphilitic  Affections  of  the  Rectum  and  Anus,"  Morrow's  "System  of 

Genito-Urinary  Diseases,"  vol.  ii,  pp.  417-36,  1893. 
Woodward:     "Medical   and  Surgical  History   of  the   War   of  the  Rebellion," 

Med.  Vol.,  Pt.  II,  vol.  i,  p.  504,  1879. 
Zappula:     "Un   ravo   di   stringiments  del  retto   per   causa   syphilitica,"   Ann. 

Univ.  di  Med.,  Milano,  ccxlU,  p.  157,  1870. 
Ziegler:    "Syphilis  of  the  Intestine,"  "Spec.  Path.  Anat."   (American  edition), 

p.  674,  1898. 

"Dysentery,"  ibid.,  p.  663,  1898. 


XITERATIJRE  ON  ESTHIOMENE 


Auspitz:    Gazette  Eehd.,  Fev.  24,  1885. 

Deschamps:    "Etude  sur  quelques  Ulcerations  Rares  et  Non-veneriennes  de  la 

Vulve  et  du  Vagine,"  Arch,  de  TocoL,  p.  19,  1885. 
Foster:    "Lupus  Exedens,"  Jour.  Med.  and  Science,  vol.  v,  p.  143,  1899. 
Huguier:    "Esthiomene  of  the  Vulvo-anal  Region,"  Mem.  de  VAcademie,  t.  xiv, 

p.  508.    Paris,  1848. 
Macdonald:     "Lupus  of  the  Vulvo-anal  Region,"  Edinburgh  Med.  Jour.,  vol. 

xxix,  p.  909,  1885. 
Peckham:     "Ulcerative   Lesions   of   the   Vulva,   Commonly   Called   Lupus,   or 

Esthiomene,"  Jour.  Obstet.  and  Dis.  Women  and  Children,  vol.  xx,  p.  783, 

Jan.  4,  1890. 
Taylor,  R.  W.:    "Lupus  of  Vulvo-anal  Region,"  A".  Y.  Med.  Jour.,  Jan.  4,  1890. 


CHAPTER  XXIV 

NON=MALIQNANT  STRICTURE 

Stricture  of  the  rectum  is  a  narrowing  of  the  lumen  of 
the  bowel  from  any  cause  (Plate  XX).  Stricture  is  com- 
paratively rare,  and  may  be  congenital  or  acquired.  It  may 
occur  at  any  age,  and  is  encountered  far  more  frequently  in 
women  than  in  men. 

According  to  Allingham's  statistics,  stricture  constitutes 
4.4  per  cent,  of  all  rectal  diseases.  It  is  most  common  between 
the  ages  of  twenty  and  forty  years,  and  is  exceedingly  rare  in 
children.  The  writer  has  had  the  good  fortune  to  see  four 
cases  in  children  under  thirteen  years  of  age.  One  of  these 
was  in  a  negro  girl,  13  years  old,  who  had  acquired  syphilis ; 
another  was  in  a  boy  of  eighteen  months,  and  was  caused  by 
swallowing  an  open  safety-pin,  which  lodged  in  the  rectum  and 
induced  extensive  ulceration.  In  the  two  remaining  cases  the 
stenosis  was  congenital :  one  was  due  to  congenital  narrowing 
of  the  anal  canal ;  the  other  was  of  the  so-called  diaphragmatic 
variety,  and  evidently  the  result  of  undue  development  of  the 
two  lowermost  "rectal  valves,"  which,  in  this  case,  were  situated 
directly  opposite  each  other. 

Rectal  stenosis  is  very  common  in  the  colored  race.  This 
is  very  probably  due  to  their  tubercular  tendency  and  the  fre- 
quent occurrence  of  syphilis  among  them.  In  Kansas  City, 
where  the  majority  of  persons  applying  for  treatment  at  the 
author's  clinic  were  negroes,  20  per  cent,  of  the  rectal  cases 
were  strictures. 

As  a  rule,  stricture  is  single ;  in  exceptional  cases,  how- 
ever, the  bowel  may  be  constricted  at  more  than  one  point. 
It  may  consist  of  but  a  narrow  ring  encircling  the  rectum, 
annular  stricture  (Fig.  107),  or  the  diminution  of  the  lumen 
may  extend  along  several  inches  or  even  the  entire  length 
of  the  rectum,  tubular  stricture  (Fig.  108).  When  the  bowel 
is  entirely  occluded,  it  is  designated  complete  stricture;  when 
fecal  matter  escapes  through  the  constriction,  it  is  known  as 
partial  stricture.  The  stenosis  may  be  located  at  the  anus  or 
in  any  part  of  the  rectum.  Its  most  frequent  site,  however,  is 
from  one  to  two  and  one-half  inches  (2.54  to  6.4  centimeters) 
(348^ 


NON-MALIGNANT  STRICTURE 


349 


above  the  anus,  the  majority  being  situated  at  the  point  where 
the  levator  ani  muscles  embrace  the  bowel. 

ETIOLOGY  AND   PATHOLOGY 

The  rectum  is  more  frequently  the  site  of  stricture  than 
any  other  canal  opening  upon  the  surface  of  the  body.  This 
is  dependent  upon   its   anatomic  arrangement  and   function, 


Fig.  107. — Diagrammatic  Drawing  of 
Annular  Stricture.  , 


Fig.   108.— Diagrammatic  Drawing  of 
Tubular  Stricture. 


which  constantly  expose  it  to  injury  and  stretching,  and  also 
upon  the  presence  at  all  times  of  pathogenic  bacteria.  Fur- 
thermore, its  relation  to  adjacent  organs  renders  it  particularly 
liable  to  infection  from  disease  in  these  organs. 

Although  many  theories  have  been  advanced  to  explain 
the  more  common  occurrence  of  stricture  among  women  than 
men,  no  single  explanation  of  this  fact  has  been  entirely  satis- 
factory.   This  is,  no  doubt,  due  to  the  failure  of  any  one  theory 


350  DISEASES  OF  THE  RECTUM  AND  ANUS 

to  cover  the  many  conditions  which  render  women  more  sus- 
ceptible to  stricture.  These  conditions  are  the  HabiHty  of  the 
rectum  to  injury  during  labor,  or  to  pressure  against  the  bony 
structure  by  an  enlarged  or  retroverted  uterus,  injury  during 
coitus,  interference  with  the  circulation  in  pregnancy,  the 
danger  of  infection  from  venereal  lesions,  and  extension  of 
inflammation  from  disease  of  the  ovaries,  tubes,  uterus,  and 
vagina;  moreover,  women  suffer  from  constipation  and  conse- 
quent traumatism  more  often  than  men.  Rieder  suggests  the 
following  as  an  explanation  of  the  more  frequent  occurrence 
of  syphilitic  stricture  in  the  female :  In  the  female  the  lowest 
group  of  rectal  veins  anastomose  directly  with  the  external 
pudendal,  which  arise  from  the  posterior  vulvar  commissure, 
the  usual  location  of  the  primary  and  secondary  sores,  and 
nearly  always  of  the  tertiary.  Thus,  the  syphilitic  virus  is  car- 
ried directly  into  the  hemorrhoidal  veins,  and  finds  lodgment  in 
the  rectum.  In  the  male  the  poison  must  be  carried  in  a  more 
roundabout  way  from  the  penis  and  foreskin  to  the  vesic  plexus, 
thence  to  the  rectal  veins. 

Stricture  of  the  rectum  may  be  classified  from  an  etiologic 
stand-point  as  follows  : — 

1.  Congenital.  6.  Dysenteric. 

2.  Traumatic.  7.  Varicose       (hemor- 

3.  Venereal.  rhoidal). 

4.  Catarrhal.  8.  Valvular  and  bandular. 

5.  Tubercular.  9.  Spasmodic. 

10.  Pressure  upon  the  rectum  by  diseased 
organs  and  tumors. 

The  etiology  and  pathology  of  the  different  varieties  of 
stricture  have,  in  a  large  measure,  already  been  given  in  the 
chapters  on  congenital  malformations,  proctitis,  venereal  dis- 
eases, ulceration,  constipation,  and  fissure.  It  only  remains 
to  here  supplement  and  emphasize  the  more  important  points 
given  in  those  chapters. 

Congenital  Stricture  of  the  rectum  is  very  rare,  and  occurs 
most  frequently  in  boys.  Statistics  collected  by  Cooper  and 
Edwards  give  but  one  malformation  of  the  rectum  and  anus 
in  every  eleven  thousand  births.  When  it  is  considered  that 
stricture  of  the  bowel  exists  in  only  a  small  proportion  of  such 
malformations,  the  rarity  of  congenital  stricture  can  be  appre- 


NON-MALIGNANT  STRICTURE  351 

dated.  This  form  of  stricture  may  be  annular  or  tubular, 
partial  or  complete ;  the  stenosis  may  be  at  the  anus  or  at  any 
point  in  the  rectum,  and  be  complicated  with  fistula  leading 
to  the  bladder,  urethra,  or  vagina. 

Traumatic  Stricture  is  more  frequent  than  is  generally  sup- 
posed. It  is  more  common  among  women  than  men.  Any 
traumatism  which  causes  ulceration  of  the  rectum,  proctitis,  or 
perirectal  inflammation  may  result  in  traumatic  stricture.  The 
most  common  causes  of  this  form  of  stricture  are  constipation, 
fecal  impaction,  surgical  operations,  pederasty,  injury  to  the 
rectum  by  the  child's  head  during  parturition,  pessaries,  fre- 
quent enemata,  strong  and  irritating  purgatives,  direct  injuries 
by  external  violence  or  from  the  improper  use  of  instruments, 
the  manipulation  of  tumors, — such  as  hemorrhoids  or  polyps, — 
and  prolapse  which  m.ay  require  replacement.  Owing  to  ex- 
posure to  infection  and  constant  stretching  and  mechanic  irri- 
tation exerted  by  the  feces,  any  slight  or  extensive  injury  to 
the  rectum  may  result  in  ulceration  tending  to  spread  and 
deepen  and  which,  when  healed,  may  leave  sufficient  cicatrix 
to  produce  partial  or  complete  stricture.  Bullard  claims  that 
traumatism  is  by  far  the  most  common  cause  of  stricture  of 
the  rectum,  and  he  asserts  that  not  more  than  one  in  a  thou- 
sand cases  of  stricture  is  due  to  chancroids  or  syphilitic  lesions. 

Venereal  Stricture  may  be  caused  by  syphilis  (congenital 
or  acquired),  chancroids,  or  gonorrhea. 

If  statistics  are  to  be  relied  upon,  syphilis  is  the  most  com- 
mon cause  of  stenosis  of  the  rectum.  Just  what  percentage  of 
rectal  strictures  are  due  to  syphilis  has  been  a  subject  of  con- 
tention among  proctologists  for  years  past  and  is  still  a  much- 
mooted  question.  Cooper  and  Edwards  claim  that  a  syphilitic 
history  is  obtainable  in  from  25  to  30  per  cent,  of  all  cases  of 
non-malignant  stricture  of  the  rectum. 

Allingham  endeavors  to  throw  some  light  on  this  question 
by  recording  100  cases  observed  by  him  in  private  practice 
and  at  St.  Mark's  Hospital,  London.  He  says :  "On  summing 
up  my  own  statistics  I  can,  in  short,  state  that,  in  women,  42 
out  of  80  had  suffered  from,  or  were  suffering  from,  undoubted 
constitutional  syphilis,  and,  in  20  males,  half  were  in  the  same 
condition ;  thus,  out  of  a  total  of  100  patients,  52,  or  more  than 
half,  were  syphilitic."  He  ascribes  the  cause  in  the  other  48 
cases  to  tuberculosis,   dysentery,   diarrhea,   constipation,   and 


352  DISEASES  OF  THE  RECTUM  AND  ANUS 

surgical  operations,  while  in  a  large  number  he  was  unable  to 
assign  any  cause. 

Cripps  places  on  record  70  cases  of  stricture  admitted  to 
St.  Bartholomew's  Hospital,  and  gives  the  probable  primary 
causes  as  follows : — 

Table  XI.     Cripps's  Table  of  Steicture 

1.  Syphilis    13 

2.  Childbirth    8 

3.  Operations  for  piles  8 

4.  Operations  for  fistula 2 

5.  Congenital     2 

6.  Inflammation  of  the  bo^vels 2 

7.  Internal  fistula   2 

8.  Dysentery    2 

9.  Tubercular  diseases   1 

10.  Unassigned    30 

Total    70 

Of  the  70  cases,  63  occurred  in  women  and  7  in  men. 
From  the  foregoing  table  it  would  appear  that  18  per  cent, 
represents  as  nearly  as  possible  the  proportion  of  cases  of 
stricture  which  can  be  fairly  assigned  to  syphilitic  origin. 
Cripps  believes  that  some  authors  attribute  stricture  to  syph- 
ilis without  due  evidence,  and  asks  why  it  is  that  this  diathesis 
should  so  much  more  frequently  lead  to  stricture  in  women 
than  in  men ;  for  a  much  larger  number  of  males  than  females 
suffer  from  syphilis,  exactly  reversed  in  the  frequency  of 
stricture.  He  believes  that  the  true  explanation  of  the  pre- 
ponderance of  this  disease  in  females,  whether  specific  or  other- 
wise, is  to  be  sought  for  in  the  anatomic  relations  of  the  rectum 
rather  than  in  any  constitutional  diathesis. 

The  following  table,  which  also  appeared  in  a  former  edi- 
tion of  this  work,  gives  the  probable  cause  in  25  cases  of  non- 
malignant  stricture  of  the  rectum,  treated  by  the  writer  during 
the  two  years  1894-95  : — - 

Table  XII.     Author's  Table  of  Stricture 

1.  Syphilis    13 

2.  Tuberculosis   2 

3.  Diarrhea    2 

4.  Dysentery    1 

•  5.  Rectal  catarrh 2 

G.  Traumatism    2 

7.  Unknown     3 

Total    25 


NOJsT-lNIALIGNANT  STRICTURE  353 

Of  the  25  cases,  20  were  in  women  and  5  in  men;  13,  or  more 
than  one-hah'  the  total  number,  had  syphihs. 

Since  1895  the  author  has  treated  a  large  number  of  cases 
of  non-malignant  stricture  of  the  rectum.  The  patients  were 
from  eighteen  months  to  sixty  years  of  age,  the  majority  being 
women,  and  the  greater  number  in  middle  life.  In  a  few  of 
these  cases  it  was  impossible  to  ascertain  the  cause  of  the 
stricture,  owing  to  the  unsatisfactory  history  obtainable  and 
the  fact  that  stricture  had  existed  for  some  time  before  the 
patient  applied  for  treatment.  In  the  remainder,  however,  the 
stenosis  was  undoubtedly  either  directly  or  indirectly  due  to 
the  following  causes :  Chancre,  secondary  syphilitic  ulceration, 
gummata,  chancroids,  proliferating  stenosing  proctitis,  chronic 
hypertrophic  proctitis,  gonorrhea,  traumatism  from  foreign 
bodies,  fecal  impaction,  external  violence  (impaling),  tuberculo- 
sis, varicose  (hemorrhoidal)  ulceration,  parturition,  ulceration 
following  rectal  operations  (Whitehead's  operation),  pressure 
from  retroverted  and  fixed  uterus,  urinary  calculus,  congenital 
malformation  of  the  rectum  and  anus,  fibroids  of  the  uterus,  rup- 
ture of  the  urethra  (from  fall)  and  extravasation  of  urine  (fol- 
lowed by  sloughing),  and  h3'pertrophied  and  abnormally  placed 
"rectal  valves." 

From  a  careful  study  of  these  cases  and  consideration  of 
the  statistics  of  others,  the  author  is  fully  convinced  that,  al- 
though syphilis  is  not  as  common  a  cause  of  stricture  as  some 
writers  would  imply,  it  is,  nevertheless,  a  very  frequent  cause. 
He  is  likewise  of  the  opinion  that  the  stenosis  may  be  the  result 
of  congenital  syphilis,  extensive  ulcerations  from  chancre, 
secondary,  syphilitic  ulceration,  ano-rectal  syphiloma,  or  gum- 
matous deposits  which  may  occlude  the  rectum  or  break  down 
and  ulcerate.  Even  though  no  syphilitic  lesions  have  occurred 
in  the  rectum,  the  disease  lowers  the  powers  of  resistance  and 
also  attacks  the  blood-vessels  of  the  rectum,  thus  rendering  its 
victims  susceptible  to  ulceration.  Indeed,  in  these  persons  a 
slight  injury  may  result  in  inflammatory  thickening  or  exten- 
sive ulceration,  followed  by  partial  or  complete  stricture. 

Bullard  holds  that  syphilis  produces  stricture  only  by 
weakening  the  system  and  causing  endarteritis,  thus  leaving  the 
mucous  membrane  poorly  nourished  and  liable  to  ulcerate  from 
any  cause.  Contrary  to  this,  Rieder  maintains  that,  of  the 
vascular  system,  the  veins  only  are  diseased.     The  post-mortem 


354  DISEASES  OF  THE  RECTUM  AND  ANUS 

examinations  by  Rieder  in  cases  of  syphilitic  stricture  demon- 
strated that,  while  the  arteries  were  normal,  the  veins  were  in- 
variably diseased,  there  being  either  an  endophlebitis  of  the 
intima  or  a  change  of  the  stratum  of  subendothelial  cells  to  a 
thick,  fibrous  mass.  Furthermore,  there  was  chronic  inflam- 
matory cellular  infiltration  of  all  the  layers  of  the  gut-wall, 
consisting  principally  of  round,  epithelioid,  and  giant  cells,  and 
the  distribution  of  pathologic  products  corresponded  to  vessels. 

According  to  Gosselin  and  Mason,  cJiancroids  are  the  most 
frequent  cause  of  stricture  of  the  rectum.  Other  equally  high 
authorities,  including  Allingham,  maintain  that  rectal  stenosis 
rarely,  if  ever,  results  from  this  cause. 

Except  when  ulceration  is  prolonged  and  extensive 
through  neglect  or  improper  treatment  or  where  they  have 
become  phagedenic,  chancroidal  ulcers,  when  healed,  do  not 
leave  sufficient  scar-tissue  to  produce  constriction  of  the  bowel. 
The  writer  has  seen  but  two  cases  of  stricture  of  the  rectum 
following  chancroidal  ulceration.  Both  of  these  were  tight 
strictures  involving  the  lower  half-inch  of  the  anal  canal  and 
due  to  contraction  following  destruction  of  the  skin  and  mu- 
cous membrane.  As  these  two  cases  were  under  the  observa- 
tion of  the  writer  from  shortly  after  the  onset  of  the  disease 
to  the  occurrence  of  stenosis,  he  is  positive  of  the  diagnosis. 
The  lesions  were  typically  characteristic,  and  there  was  at  no 
time  any  indication  that  the  sores  were  of  syphilitic  origin. 

Gonorrhea  of  the  rectum  is  an  extremely  rare  cause  of 
stricture.  Diminution  of  the  caliber  of  the  bowel  from  gonor- 
rhea may  be  due  either  to  thickening  of  the  gut-wall  from  the 
inflammatory  process  or  to  necrotic  ulceration  when  the  cir- 
culation has  been  interfered  with  by  the  deposits.  The  author 
has  seen  the  mucosa  much  thickened  and  the  sphincter-muscle 
hypertrophied  from  gonorrhea,  but  has  never  met  with  a  tight 
stricture  from  this  cause. 

Catarrhal  Inflammation  of  the  rectum  not  infrequently 
causes  partial  or  complete  occlusion  of  the  bowel.  In  fact, 
Bullard  maintains  that  a  large  majority  of  all  strictures  of  the 
rectum  are  the  result  of  traumatic  proctitis.  Proctitis  may 
produce  a  stricture  of  the  rectum  in  any  one  of  the  following 
ways :  (1)  by  causing  inflammatory  deposits ;  (2)  when  of  the 
ulcerative  variety,  by  the  formation  of  cicatricial  tissue ;  (3) 
when  of  the  hypertrophic  form,  it  may,  in  rare  cases,  produce 


NON-MALIGNANT  STRICTURE  355 

cauliflower-like  vegetations  which  occkide  the  bowel ;  (4)  when 
of  the  proliferating-  stenosing  variety  described  by  Hammonic, 
a  long,  tubular  stricture  may  result  from  increased  formation 
of  fibrous  tissue  without  ulceration  (Fig.  109). 

Tubercular  Stricture  is  exceedingly  rare,  for,  while  tuber- 
cular ulcers  in  the  ano-rectal  region  are  not  uncommon,  they 
rarely  heal,  and  therefore  no  scar-tissue  is  produced.  The 
author  has  seen  but  three  cases  of  rectal  stenosis  due  to  healing 
of  tubercular  ulcers,  the  most  typic  of  which  was  referred  to 


Fig.  109.— Complete  Tubular  Stricture  of  the  Rectum  Due  to  Clironlc  Prolif- 
erating Stenosing  Proctitis.  Rectum  Split  Open  to  Show  Inflammatory 
Thickening. 

him  by  his  colleague,  Prof.  Herman  J.  Boldt.  Ouenu  and 
Hartmann  are  skeptic  whether  stricture  is  ever  produced  in 
this  way,  but  Allingham,  Kummel,  Tellarix,  and  Sourdelli  have 
published  such  cases.  Sourdelli,  in  a  case  reported  in  1894, 
submitted  in  detail  bacteriologic  findings  which  supported  his 
diagnosis.  A  few  cases  of  stricture  of  the  rectum  due  to  exten- 
sion of  perirectal  inflammation  of  tubercular  origin  are  on 
record.    The  author  has  never  seen  a  case  caused  in  this  way. 

Varicose  Ulcers  secondary  to  breaking  down  of  enlarged 
veins  in  the  lower  rectum  and  ulcers  caused  by  sloughing  of 


356  DISEASES  OF  THE  RECTU:\I  AKD  ANUS 

strangulated  hemorrhoids  may,  when  healed,  leave  a  sufficient 
cicatrix  to  produce  stenosis  of  the  lower  rectum.  The  author 
has  seen  two  cases  of  stricture  due  to  this  cause. 

Valvular  Stricture  may  be  congenital  or  acquired,  and  is 
comparatively  rare.  When  one  of  the  "rectal  valves"  (Hous- 
ton's) completely  encircles  the  rectum,  leaving  but  a  small 
opening  in  the  center,  it  is  called  diaphragmatic,  or  membranous, 
stricture.  Partial  occlusion  may  be  produced  by  hypertrophy 
of  a  "valve"  or  by  two  overdeveloped  "valves"  situated  directly 
opposite  each  other  (Plate  V).  The  author  recently  examined 
a  child,  18  months  of  age,  who  was  suffering  from  the  latter 
iorm  of  stricture. 

Valvular  stricture  may  be  confused  with  bandular  stricture, 
Avhich  is  produced  by  a  band  of  fibrous  tissue  extending  around 
or  across  the  rectum.  Bandular  stricture  may  be  congenital  or 
the  result  of  scar-tissue  left  after  healing  of  an  ulceration. 

Spasmodic  or  Phantom  stricture  has  always  been  the  subject 
of  much  controversy  among  proctologists.  The  bone  of  con- 
tention has  been :  is  the  spasmodic  contraction  sometimes  ob- 
served a  real  stricture  of  the  rectum,  or  is  it  a  symptom  of 
some  other  pathologic  condition? 

Van  Buren  says :  "Wherever  muscular  spasm  exists,  vol- 
untary or  otherwise,  there  must  be  a  cause,  reflex  or  direct, 
and  this  cause  is  to  be  recognized  as  the  disease,  and  not  the 
narrowing  to  which  it  gives  rise.  Permanent  spasm  of  invol- 
untary muscle  I  regard  as  an  impossibility." 

Again  he  says :  "Neither  in  imaginary  nor  in  actual  strict- 
ure is  muscular  spasm  an  element  of  any  practical  importance." 

Leichtenstern  says :  "The  existence  of  such  an  affection 
no  longer  calls  for  serious  discussion." 

Mr.  Harrison  Cripps,  after  agreeing  with  Van  Buren 
and  other  writers  that  permanent  spasm  of  the  involuntary 
muscular  fiber  is  a  physiologic  impossibility,  says:  "There 
is  a  condition  of  temporary — followed  by  permanent — short- 
ening to  which  muscles,  frequently  stimulated  by  reflex 
irritation,  are  liable."  In  proof  of  this  statement,  he  cites  un- 
treated cases  of  chronic  knee-joint  disease.  He  argues  that 
any  irritation,  as  an  ulcer,  inducing  continual  reflex  contraction 
in  any  muscular  canal,  might  terminate  in  permanent  shorten- 
ing of  its  fibrous  elements,  thus  producing  an  annular  stricture, 
and  in  these  views  Mr.  Ball,  of  Dublin,  concurs. 


PLATE   XX.— DIAGRAMMATIC   DRAWING    OF    RECTAL 
STRICTURE   DUE    TO    ULCERATION. 

A,  Dilated  rectum  above  stricture. 

B,  Thickened  walls  neoA-  constriction. 

C,  Ulceration  at  and  above  the  stricture. 


NON-MALIGNANT  STRICTURE  357 

•     The  author  has  treated  many  cases  of  hypertrophy  of  the 
sphincter-muscle  the  result  of  spasmodic  contraction.     In  every 
case  he  has  been  able  to  trace  the  cause  to  irritation  induced 
by  a  fissure  or  other  disease  about  the  rectum  or  anus,  or  to 
reflex  disturbances   from  neighboring  organs.     He  has  also 
seen  the  levatores  ani  so  hypertrophied  from  similar  causes  that 
they  could  be  distinctly  outlined  and  felt  to  contract  by  the 
finger  in  the  rectum,  especially  when  the  patient  was  requested 
to  draw  the  anus  upward.     He  has  never  seen  spasmodic  con- 
traction above  the  levatores  ani,  and  he  does  not  believe  that 
any  such  condition  as  phantom  stricture  exists.     On  the  con- 
trary,  he  is   of  the  opinion  that  the  condition   described  as 
phantom  stricture  is,  in  reality,  a  spasmodic  contraction  of  the 
sphincter  or  levator  ani  muscles  due  to  irritation  from  some 
definite  lesion  about  the  rectum  or  anus  or  neighboring  or- 
gans.    Furthermore,  the  narrowest  point  in  the  bowel  above 
the  levatores  ani  is  at  O'Beirne's  sphincter  or  the  recto-sig- 
moidal  junction,  and  it  is  not  improbable  that  this  narrowing 
in  the  bowel  has  been  mistaken  for  phantom  stricture.     The 
writer  believes  that  the  "rectal  valves"  have  been  frequently 
confused  with  this  condition.    This  is  not  surprising,  since  the 
rectum  is  capable  of  considerable  vertical  motion,  and  when  a 
patient  is  examined  at  one  time  the  "rectal  valves"  may  be 
distinctly  felt,  while  at  a  subsequent  examination  they  will  be 
out  of  reach  of  the  finger. 

Pressure  upon  the  Rectum  by  Diseased  Organs  and  Tumors 
sometimes  causes  occlusion  of  the  bowel.  Such  diminution  in 
the  bowel-caliber  may  be  produced  by  a  retroverted  uterus,  or 
by  tumors  of  the  prostate,  bladder,  uterus,  vagina,  tubes, 
ovaries,  or  sacro-coccygeal  region. 

PATHOLOGY 

Before  considering  the  symptoms,  the  author  will  briefly 
review  the  gross  pathology  as  observed  in  a  typic  case  of  strict- 
ure of  the  rectum  which  has  existed  for  some  time.  Not  only 
are  the  mucous  membrane  and  the  muscular  coats  of  the  rec- 
tum diseased  at  the  point  of  constriction,  but  frequently  both  above 
and  below  (Plate  XX).  On  post-mortem  examination,  a  sec- 
tion of  the  stricture  (Fig.  110)  will,  in  most  instances,  creak 
when  pressed  between  the  fingers,  be  firm  to  the  touch,  of 
glistening  appearance,  like  other  scar-tissue,  and  ofifer  much 


358 


DISEASES  OF  THE  RECTUM  AND  ANUS 


resistance  to  the  knife.  There  will  be  found  an  abundant  in- 
crease of  connective  tissue  at  the  seat  of  the  stricture  and  in 
its  immediate  vicinity;  all  of  the  rectal  coats  and  the  tissues 
beneath  them  and  in  the  ischio-rectal  fossae  will  be  found  in- 
durated and  fixed.  In  cases  of  long  standing  ulceration  and 
irregular  nodules  can  be  felt  above  and  below  the  strictured 
point  (Plate  XX).  Dilatation  of  the  rectum  above  the  con- 
striction always  takes  place, — due  largely  to  fecal  impaction, — 
while  narrowing  is  the  rule  below  the  stricture.  Fistula  is  a 
frequent  complication,  and  acts  as  a  sewer  to  carry  off  the 
discharge  from  the  ulcerations.  A  fistula  opens  more  fre- 
quently  above   than   below   the   stricture.      Around   the   anal 


Fig.  110.— Appearance  of  a  Cross-section  of  Strictured  Rectum. 

margin  and  lower  part  of  the  rectum  there  are  often  vege- 
tations, piles,  and  tags  of  skin,  which  are  indicative  of  a 
chronic  discharge.  When  the  fistula  becomes  stopped  up  or 
the  submucous  tissue  becomes  infected  from  the  poisonous 
discharges,  an  abscess  will  result.  This  abscess  may  open  into 
the  bladder,  the  vagina,  or  upon  the  surface  of  the  body. 
Frequently  the  intestines  will  be  bound  together  by  bands  of 
adhesions  the  result  of  chronic  peritonitis.  In  one  fatal  case, 
where  the  writer  succeeded  in  getting  a  post-mortem  examina- 
tion, the  intestines  were  found  matted  together  and  covered 
with  pus. 

SYMPTOMS 

The  symptoms  of  rectal  stricture  must  necessarily  be  both 
local  and  general.  The  former  are  due  to  ulceration.  The 
latter  are  caused  by  mechanic  obstruction  of  the  alimentary 


NON-MALIGNANT  STRICTURE  359 

canal;  such  an  obstruction  creates  a  disturbance  in  both  the 
circulatory  and  the  nervous  systems  and  causes  a  long  train 
of  misleading  symptoms.  Stricture  is  quite  frequently  over- 
looked until  obstruction  takes  place.  The  early  symptoms 
of  stricture  are  almost  identic  with  those  of  ulceration,  re- 
ferred to  in  the  previous  chapter.  The  earliest  symptom  is 
usually  that  of  constipation.  For  a  time  these, patients  get  on 
without  medicine ;  as  the  constriction  narrows  down,  however, 
purgatives  are  taken,  the  stools  are  softened,  and  all  goes  well 
for  a  few  months  longer.  The  patient  then  observes  that  a 
longer  time  is  required  for  stool  and  that  much  straining  is 
necessary  before  the  bowel  can  be  thoroughly  emptied.  As 
time  goes  on,  straining  increases,  and,  instead  of  continued 
constipation,  diarrhea  alternates  with  constipation.  As  the 
constriction  becomes  tighter  and  tighter,  constipation  ceases, 
diarrhea  predominates,  and  the  patient  is  forced  to  go  to  stool 
many  times  a  day;  in  fact,  during  the  later  stages  of  the  dis- 
ease the  sufferer  spends  half  his  time  in  the  closet  and  fre- 
quently passes  small  quantities  of  liquid  feces.  There  is  a 
ceaseless  feeling  that  the  bowel  has  not  been  thoroughly  emp- 
tied and  that  something  is  yet  to  come  away.  It  is  necessary 
to  take  the  strongest  cathartics,  followed  by  copious  injections 
of  warm  water  and  glycerin  to  liquefy  the  feces,  before  they 
can  be  voided.  The  straining  and  tenesmus  which  accompany 
the  frequent  stools  are  something  frightful ;  indeed,  the  writer 
is  unacquainted  with  any  other  condition  that  will  induce  so 
much  suffering.  The  pain  is  described  as  bearing  down,  and  is 
probably  the  result  of  a  large,  hard  lump  of  fecal  matter  which 
rests  upon  the  upper  surface  of  the  stricture,  but  cannot  be 
forced  through  it.  The  pain  during  the  intervals  of  straining 
is  nominal.  In  cases  of  long  standing  the  pain  is  reflected  to 
the  neighboring  organs,  up  the  back,  over  the  abdomen,  and 
down  the  limbs.  Cramping  of  the  lower  extremities  is  not  an 
uncommon  symptom  of  stricture. 

Patients  suffering  from  stricture  invariably  have  a  worn- 
out,  pinched  expression  about  the  face.  The  tongue  is  coated, 
the  breath  very  offensive,  and  the  skin  appears  sleek  and  waxy. 
The  general  appearance  is  much  like  that  of  one  suffering  from 
general  tuberculosis. 

Character  of  the  Stools. — Much  knowledge  is  to  be  gained 
from  a  close  inspection  of  the  stools.    Too  much  reliance,  how- 


360  DISEASES  OF  THE  RECTUM  AND  ANUS 

ever,  should  not  be  placed  on  the  sJiope  of  the  feces,  for  this 
is  sometimes  very  deceptive,  and  cannot  be  accepted  as  a  posi- 
tive diagnostic  sign  of  stricture,  the  statements  of  many  text- 
books on  general  surgery  to  the  contrary  notwithstanding. 
They  are  never,  or  rarely  ever,  normal  in  shape  when  the 
stricture  is  tight,  but  are  described  as  resembling  in  shape  a 
pipe-stem,  piece  of  ribbon,  or  tape,  and  very  long;  sometimes 
the  fecal  movements  are  flat  or  round.  The  author  has  seen 
cases  of  higJi  stricture  where  the  stools  were  large,  hard,  and 
almost  normal  in  shape.  Many  of  the  older  authors  would 
have  held  that  stricture  did  not  exist  in  these  cases.  The  ex- 
planation of  this  is  that  the  soft  and  semisolid  feces  pass 
through  the  stricture  into  the  lower  portion  of  the  rectum. 
If  not  too  soon  discharged,  absorption  of  the  watery  portion 
takes  place  and,  if  a  sufficient  quantity  of  feces  has  come  down, 
a  well-formed  stool  may  be  discharged.  On  the  other  hand, 
ribbon-like  stools  may  be  evacuated  when  there  is  not  the  slight- 
est sign  of  a  stricture,  owing  to  the  spasmodic  contraction  of  the 
sphincter-muscle  induced  by  fissure,  ulcer,  etc.  When  a  tape 
or  ribbon-like  stool  is  of  frequent  occurrence,  however,  a  strict- 
ure should  be  suspected,  and  a  careful  examination  should  then 
be  made. 

Some  years  ago,  in  the  University  Medical  College,  Kan- 
sas City,  the  author  had  the  unusual  opportunity  of  demon- 
strating to  his  class  the  manner  in  which  the  stools  were  formed 
and  discharged  through  a  stricture.  The  case  was  that  of  a 
woman  who  was  being  anesthetized  for  operation.  The  sphinc- 
ter had  been  thoroughly  divulsed,  and  the  stricture,  which  was 
located  three  inches  (7.62  centimeters)  above  the  anus,  was 
about  to  be  incised,  when  the  patient  commenced  to  strain  and 
vomit.  The  stricture  was  forced  down  through  the  external 
sphincter  and  presented  to  the  full  view  of  everyone.  Just  then 
the  straining  ceased,  and  a  string  of  solid  feces,  about  the  size 
of  an  ordinary  lead-pencil  and  two  feet  long,  was  expelled 
through  the  constricted  orifice.  This  was  followed  by  a  dis- 
charge of  liquid  feces,  which  was  propelled  with  such  force  as 
to  lodge  against  a  wall,  some  five  feet  (1.5  meters)  away. 

Peritonitis,  either  acute  or  chronic,  occurs  sooner  or  later 
in  almost  every  case,  and  when  chronic  continues  until  the 
stricture  is  cured  or  death  ensues.  A  post-mortem  examination 
will,  in  nearly  every  case,  confirm  this  statement. 


NON-MALIGNANT  STRICTURE  361 

Complications. — -As  a  result  of  constant  straining,  venous 
congestion,  irritating  discharges,  etc.,  other  forms  of  rectal 
disease — such  as  hemorrhoids,  abscess,  fistula,  ulcer,  fissure, 
and  pruritus  ani — will  ensue,  and  cannot  be  cured  until  the  in- 
testinal stricture  has  been  relieved. 

External  Appearance  of  the  Anus.  —  The  anus  is  usually 
patulous,'  and  the  sphincters  loose  and  flabby,  to  such  an  ex- 
tent that  the  patients  have  scarcely  any  control  over  the  feces 
when  once  they  pass  the  stricture.  Numerous  vegetations, 
tags,  and  flaps  of  superfluous  skin  are  to  be  seen  on  every  side, 
or,  possibly,  an  eczema  or  long,  deep  cracks,  which  radiate 
from  the  anus  in  every  direction  and  produce  a  persistent 
itching. 

In  conclusion,  the  more  common  symptoms  and  compli- 
cations liable  to  occur  in  a  case  of  stricture  of  the  rectum  may 
be  briefly  stated.     They  are: — 

1.  Constipation. 

2.  Diarrhea,  alternating  with  constipation. 

3.  Intense  and  almost  constant  straining. 

4.  Emaciation. 

5.  Feeling  as  if  the  bowel  never  completely  emptied  itself. 

6.  Stercoremia. 

7.  Irregular  temperature. 

8.  Indigestion. 

9.  Vesical  disturbances. 

10.  Tympanites. 

11.  Loss  of  sphincteric  power. 

12.  Discharges  of  blood,  pus,  and  mucus  (coffee-ground 
stools). 

13.  Pain,  local  or  reflected. 

14.  Change  in  size  and  character  of  the  feces. 

15.  Intestinal  obstruction. 

16.  Hemorrhoids. 

17.  Rupture  of  the  bowel  from  impacted  feces  and  strain- 
ing. 

18.  Abscess  and  fistula. 

19.  Pruritus. 

20.  Prolapse  of  the  uterus  or  of  the  rectum  below  the 
stricture. 


362 


DISEASES  OF  THE  RECTUM  AND  ANUS 


DIAGNOSIS 

When  the  stricture  is  located  within  two  and  a  half  or 
three  inches  (6.4  or  7.6  centimeters)  of  the  anus,  it  can  be 
diagnosticated  easily  by  passing  the  index  finger  upward  into 
the  rectum  until  the  constriction  is  felt.  If,  on  the  other  hand, 
the  stricture  is  situated  beyond  the  reach  of  the  finger,  it  is 
more  difficult  to  make  a  positive  diagnosis.  In  these  cases  the 
surgeon  has  an  excellent  chance  to  test  his  ingenuity  and  diag- 
nostic ability.  At  best  the  diagnosis  must  often  be  uncertain 
and  surrounded  with  doubt.  Numerous  cases  are  recorded 
where  persons  have  been  treated  for  stricture  by  well-known 
and    competent    surgeons,    yet    a    post-mortem    examination 


Fig.  111. — Correct  Method  of  Introducing  a  Rectal  Bougie. 


showed  that  there  was  no  stenosis.  What  the  surgeon  thought 
was  a  stricture,  in  some  cases,  must  have  been  the  promontory 
of  the  sacrum,  in  others  one  of  the  "rectal  valves"  against  which 
the  bougie  had  lodged,  giving  the  impression  to  the  hand  that 
it  had  been  stopped  by  a  constriction.  Again,  in  examining 
for  stricture  the  bougie  may  bend  upon  itself  when  it  strikes  a 
real  constriction,  thus  leading  the  surgeon  to  believe  that  no 
stricture  exists.  Our  own  Dr.  Gross  once  said :  "Stricture  of 
the  rectum  is  more  frequently  described  than  observed.'"  He  prob- 
ably referred  to  the  phantom  variety,  for  many  cases  of  the 
latter  were  being  reported  about  that  time. 

The  safest  and  most  intelligent  way  to  make  a  diagnosis 
of  stricture  is  by  the  finger,  provided  the  latter  can  reach  the 


NON-MALIGNANT  STRICTURE 


363 


constriction.  The  finger  should  be  passed  through  the  strict- 
ure opening,  in  order  to  ascertain  the  size  of  the  aperture  and 
extent  of  ulceration,  if  any,  both  above  and  below  it.  By  this 
means  tumors  pressing  on  the  rectum  can  be  located,  the  exact 
amount  of  the  bowel  included  in  the  constriction  measured,  and, 
as  a  rule,  the  character  of  the  lesions  determined.  When  the 
stricture  is  too  high  to  be  reached  by  the  finger,  the  surgeon 
must  make  use  of  the  proctoscope,  the  colonoscope,  some  one 
of  the  many  kinds  of  rectal  bougies  or  exploring  sounds  (Figs. 
Ill  and  112),  introduction  of  the  hand  into  the  bowel,  bimanual 
and  vaginal  examination,  or  exploratory  laparotomy.  The 
latter  procedure  is  best  when  there  is  any  doubt  as  to  the  exact 
location  or  character  of  the  disease.     In  nearly  every  case  the 


Fig.   112.— Bodenhamer's  Rectal  Explorer. 


proctoscope  zvill  reveal  to  the  examiner  the  exact  location  and 
nature  of  the  stricture;  it  is  by  far  the  most  reliable  and  safest 
means  of  determining  the  site  of  constriction  in  the  upper  rectum. 
When  the  stricture  is  located  in  the  upper  rectum  or  sigmoid  and 
there  has  been  a  chronic  proctitis,  the  rectal  walls  occasionally 
become  so  thickened  that  inflation  is  sometimes  impossible. 

For  purposes  of  examination  conic  or  olive-shaped  tips, 
fastened  to  a  piece  of  flexible  whalebone  (Fig.  112),  are  the 
best  bougies,  and  are  to  be  had  in  various  sizes.  In  order  to 
determine  the  exact  size  and  height  of  the  constricting  ring, 
bougies  of  different  sizes  are  passed  until  one  is  found  that  first 
meets  with  resistance,  then  goes  through  with  a  jerk,  and  pro- 


364  DISEASES  OF  THE  EECTUM  AND  ANUS 

duces  the  same  sensation  when  withdrawn.  This  gives  the  size 
and,  if  an  elastic  band  is  put  around  the  bougie  at  the  anus  when 
the  point  of  resistance  is  met,  also  determines  the  distance  of 
the  stricture  above  the  anus.  Some  allowance  must  be  made  for 
mobility  when  the  stricture  is  situated  in  the  upper,  or  movable, 
rectum.  If  the  passage  of  the  bougie  is  arrested  by  the  "rectal 
valves,"  a  soft-rubber  tube  with  an  opening  through  its  entire 
length  should  be  substituted  and  warm  water  injected  through 
it ;  this  will  push  the  "valve"  out  of  the  way,  and  the  instrument 
can  then  be  passed  farther  up  the  bowel.  Sometimes  this  pro- 
cedure must  be  repeated.  In  conjunction  with  the  use  of 
bougies,  bimanual  examination  should  be  made  to  locate  the 
disease.  In  some  cases  much  information  can  be  gained  from 
vaginal  examination. 

In  endeavoring  to  ferret  out  the  trouble  it  must  be  remem- 
bered that  certain  enlargements  of  the  prostate,  of  the  uterus, 
and  sometimes  tumors  in  and  about  the  rectum  produce  symp- 
toms not  unlike  those  present  when  a  real  stricture  of  the  bowel 
exists. 

The  differential  diagnosis  of  benign  and  malignant  strict- 
ure is  of  the  utmost  importance,  for  the  treatment  of  the  two 
differs  very  much.  The  following  table  from  Ball  illustrates 
the  more  important  points  of  difference : — 

Table  XIII.    Differential  Diagnosis  between  Non-malignant 
AND  Malignant  Stricture 

Differential  Diagnosis 
non-malignant  stricture  malignant  stricture 

1.  Generally  a  disease  of  adult  life.  1.  Generally  a  disease  of  old  age. 

2.  Essentially  chronic,  and  not  impli-       2.  Progress  comparatively  rapid  and 

eating    the    system    for    a    long  general  cachexia  soon  produced, 

time. 

3.  The   orifice   of   the   stricture   feels       3.  Masses  of  new  growth  are  to  be 

like  a  hard  ridge  in  the  tissues  felt  either  as  flat  plates  beneath 

of  the  bowel.    Polypoid  growths,  the  mucous  membrane  and   the 

if    present,    are    felt    to    be    at-  muscular    tunic,    or    as    distinct 

tached     to     the     mucous    mem-  tumors   encroaching   on   the   lu- 

brane.  men  of  the  bowel. 

4    Ulceration    of    the    mucous    mem-  4.  Ulceration,   when    present,    is   evi- 

brane  may  be  present,  but  with-  dently  the  result  of  the  breaking 

out  any  great  induration  of  the  down     of    the     neoplasm;      the 

edges.  edges   are   much   thickened   and 

infiltrated. 


NON-MALIGNANT  STRICTURE  365 

5.  The    entire    circumference    of    the       5.  Generally,  one  portion  of  the  cir- 

bo^vel   is   constricted  unless   the  cumference  is  more  obviously  in- 

stricture  is  valvular.  volved. 

6.  Pain,  throughout  the  whole  course,       6.  In    the    advanced    stages    pain    is 

in  direct  proportion  to  the  fecal  frequently   referred  to   the   sen- 

obstruction,   and   complained   of  sory  distribution  of  some  of  the 

only  during  defecation.  branches    of   the    sacral    plexus, 

due     to     direct     implication     of 

their  trunks. 

7.  Glands  not  involved.  7.  The   sacral   lymphatic   glands   can 

sometimes   be   felt   through   the 
rectum  to  be  enlarged  and  hard. 

In  order  to  arrive  at  a  correct  diagnosis  in  cases  of  strict- 
ure of  the  rectum,  it  is  most  important  to  get  a  complete  history 
of  the  case,  because,  after  the  ulceration  has  healed  and  scar- 
tissue  is  formed,  the  microscope  is  of  little  value  in  determining 
the  nature  of  the  disease,  and  this  is  also  true  in  cases  of 
stricture  due  to  chronic  inflammatory  deposits. 

PROGNOSIS 

So  far  as  a  cure  is  concerned,  the  prognosis  of  stricture  is 
usually  unfavorable,  unless  the  constriction  is  slight,  situated 
near  the  anus,  and  uncomplicated  by  grave  constitutional  dis- 
ease. Such  cases  are  rarely  seen  by  the  surgeon,  for  the  reason 
that  the  condition  in  this  stage  does  not  create  sufficient  pain 
and  annoyance  to  cause  the  patient  to  seek  medical  aid. 

The  history  of  a  case  of  stricture  is  that  the  patient  gets 
worse  and  worse,  changes  from  one  doctor  to  another  and  is 
never  satisfied  with  the  treatment  he  is  getting,  but  ever  be- 
lieves that  the  physician  is  after  his  money  irrespective  of  a 
cure.  Thus,  on  and  on  he  goes  until  he  becomes  most  miser- 
able, and  death  finally  relieves  him. 

The  physician  cannot  be  too  guarded  in  the  prognosis  of 
cases  of  stricture,  and  should  inform  patients  thus  afflicted  that 
they  will,  in  all  probability,  never  be  entirely  well.  If,  how- 
ever, they  are  willing  to  follow  his  instructions  for  weeks  or 
perhaps  months,  he  can  certainly  prolong  their  lives  and  make 
them  comfortable  while  they  live.  A  patient  who  is  misled 
into  the  belief  that  he  can  be  cured,  who  submits  to  a  course 
of  treatment,  pays  a  good  fee,  and  then  does  not  obtain  relief, 
will  never  forgive  the  person  who  thus  deceived  him.  Indeed, 
the  physician  who  is  base  enough  to  perpetrate  this  wrong  will 
be  lucky  if  a  suit  for  damages  is  avoided. 


366  DISEASES  OF  THE  RECTUM  AND  ANUS 

TREATMENT 

The  main  indications  in  the  treatment  of  stricture  of  the 
rectum  are  to  reduce  inflammation,  induration,  and  ulceration, 
and  to  enlarge  the  constricted  part  of  the  bowel  to  such  an 
extent  that  the  sufferer  may  defecate  without  pain  or  straining. 

The  treatment  of  benign  stricture  of  the  rectum  is : — 
1.  Non-operative.  2.   Surgical. 

NON=OPERATIVE   TREATMENT 

The  non-surgical  treatment  may  be  subdivided  into  (a) 
means  adopted  to  liquefy  the  feces,  (h)  means  that  induce  ab- 
sorption of  syphilitic  deposits  and  other  tumors  which  occlude 
the  bowel,  and  (c)  means  to  alleviate  pain  and  build  up  the  sys- 
tem in  general. 

(a)  Diet  always  plays  an  important  part  in  the  treatment 
of  strictures.  The  food  should  be  of  the  simplest  character, 
and  such  as  will  leave  as  little  residue  as  possible.  Milk  stands 
first  and  should  constitute  the  major  portion  of  the  diet.  Next 
come  rich,  nourishing  soups ;  soft-boiled  eggs ;  and  a  small 
amount  of  rare  beefsteak.  All  foods  known  to  produce  colic 
or  flatulence  should  be  discarded.  Laxatives  are  of  great  value,, 
because  they  liquefy  the  feces  and  allow  them  .to  be  discharged 
through  the  stricture:  a  thing  impossible  when  the  feces  are 
of  firm  consistence.  For  this  purpose  laxative  mineral  waters,, 
preferably  Carabaha,  in  liberal  quantities  daily  are  the  most 
reliable.  Next  come  mild  cathartics :  sulphur,  castor-oil,  etc. 
Strong  purgatives  are  always  contra-indicated,  though  they  are 
frequently  prescribed  by  physicians  who  are  not  aware  of  the 
real  condition  of  the  patient.  Injections  of  warm  water  or 
soap-suds  and  glycerin  or  oil,  however,  give  the  quickest  and 
most  satisfactory  relief  to  the  sufferer. 

(b)  Mercury  and  Potassium  Iodide  in  Increasing  Doses  are 
usually  resorted  to  in  the  treatment  of  strictures  due  to  syph- 
ilitic deposits  and  other  tumors  where  absorption  is  expected  to 
follow  medication.  Medication  will  be  of  no  service  where  the 
stricture  has  been  long  in  forming.  Stricture  caused  by  scar- 
tissue,  the  result  of  ulceration  from  whatever  cause,  is  un- 
changeable so  far  as  absorption  is  concerned.  Cases  in  which 
it  is  possible  to  cause  absorption  are  materially  benefited  by 
electricity,  or  gentle  massage  of  the  stricture  with  the  finger 
or  suitable  rectal  bougie. 


NON-MALIGNANT  STRICTURE  367 

(c)  Pain  and  tenesmus  are  constant  in  nearly  every  case 
of  stricture,  and  the  sufferers  are  extremely  nervous.  To  quiet 
them,  opium,  morphine,  bromides,  chloral,  trional,  sulphonal, 
and  other  hypnotics  and  anodynes  are  necessary,  but  these 
should  not  be  prescribed  indiscriminately.  It  is  preferable, 
when  possible,  to  relieve  them  by  the  local  application  of  hot 
salt,  flannels  wrung  out  of  hot  water,  or  hot  poultices  over  the 
anus,  abdomen,  sacrum,  and  pelvis.  Gentle  massage  of  the 
abdomen  helps  to  break  up  fecal  accumulations,  which  can  then 
be  discharged;  it  also  relieves  flatulency  to  a  marked  degree. 
The  patient's  general  health  must  be  improved  with  forced  feed- 
ing, tonics,  such  as  codliver-oil  and  preparations  of  iron  and  malt 
when  indicated,  and  plenty  of  out-door  exercise  should  be  insisted 
upon. 

In  addition,  ulceration  or  fistula,  when  present  as  compli- 
cations, should  be  treated  as  indicated  in  chapters  devoted  to 
these  subjects. 

SURGICAL   TREATMENT 

As  a  rule,  the  non-operative  treatment  affords  much  com- 
fort, but  it  fails  to  give  permanent  relief.  The  usual  history  of 
a  case  of  stricture  is  that  it  goes  on  from  bad  to  worse,  in  spite 
of  palliative  treatment,  until  obstruction  occurs  or  the  patient 
becomes  so  exhausted  that  surgical  procedures  must  be  resorted 
to.  None  of  the  operations  yet  devised  have  given  satisfaction 
in  all  cases  of  stricture,  yet  the  relief  following  most  of  them 
is  very  marked.  When  successful,  all  pain,  tenesmus,  diarrhea, 
and  straining  are  immediately  arrested,  and  patients  rapidly  im- 
prove. The  following  are  the  favorite  operations  for  the  relief 
of  stricture : — 

1.  Divulsion :     (a)   gradual ;     4.  Posterior  proctotomy. 

(b)  forcible.  5.  Excision. 

2.  Electrolysis.  6.  Colostomy. 

3.  Internal  proctotomy.  7.  Proctoplasty. 

8.  Bacon's  operation. 

Divulsion. — The  operation  of  divulsion  is  resorted  to  more 
frequently  than  any  other  surgical  procedure  for  the  relief  of 
stricture,  because  it  does  not  require  the  use  of  a  knife.  By  the 
proper  use  of  bougies,  many  cases  of  marked  stricture  with  ac- 


368 


DISEASES  OF  THE  RECTUM  AND  ANUS 


companying  ulceration  can  be  improved,  and  in  rare  instances 
even  a  cure  may  be  effected. 

There  is  much  difference  of  opinion  as  to  which  is  the 
better  method,  (a)  gradual  or  (b)  forcible  divulsion,  some 
claiming  that  the  former  is  preferable,  others  preferring  the 
latter.  The  writer  considers  both  operations  useful.  That 
operation  which  is  best  suited  to  the  case  under  treatment 
should  be  chosen. 

Gradual  Divulsion  is  more  popular  than  forcible  dilatation, 
for  the  reason  that  it  can  be  applied  to  any  portion  of  the 
rectum  and  without  anesthesia.  It  is  not  safe  to  dilate  the 
rectum  forcibly  when  the  stricture  is  more  than  two  and  one- 


Fig.  nS.— Ideal  Anal  Dilators  (Half-size). 


half  inches  (QA  centimeters)  above  the  anus,  on  account  of 
the  danger  of  rupturing  the  bowel  above  its  peritoneal  attach- 
ment and  causing  fatal  peritonitis.  When  gradual  divulsion 
is  practiced,  it  is  better  to  use  a  bougie  that  will  pass  the  con- 
striction with  ease  than  one  which  requires  force;  when  force 
is  used  there  is  clanger  of  rupturing  the  bowel  or  of  exciting 
inflammation  and  irritation,  which  may  do  more  harm  than  if 
the  bougie  had  not  been  passed  at  all.  There  is  nothing  more 
tempting  than  to  force  a  bougie  through  a  stricture  in  which 
it  has  lodged.  Several  deaths  have  been  recorded  from  peri- 
tonitis following  rupture  of  the  bowel-wall  due  to  carelessly  or 
ignorantly  forcing  a  large  bougie  through  a  stricture.  Patients 
treated  by  gradual  divulsion  should  be  warned  that  a  number 


NON-MALIGNANT  STRICTURE  369 

of  zvceks  or  perhaps  months  will  be  required  to  give  any  perma- 
nent benefit;  otherwise  they  may  think  they  are  being  treated 
for  their  fee  only  and  go  to  some  other  physician. 

It  is  not  at  all  necessary  that  the  surgeon  should  do  all 
the  work,  for  the  patient  can  be  taught  to  use  the  bougie  upon 
himself,  especially  when  the  constriction  is  in  the  lower  part 
of  the  rectum.  The  short  bougies  (anal  dilators)  are  prefer- 
able (Fig.  113)  in  low-seated  stricture.  They  should  be  passed 
daily  and  left  in  place  for  from  five  to  ten  minutes.  The  patient 
should  be  instructed  to  return  once  a  week  so  that  the  attend- 
ant may  see  what  progress  has  been  made. 

Gradual  dilatation  is  not  best  when  the  constriction  is  tight 
and  within  the  lower  two  inches  (5  centimeters)  of  the  rectum, 
for  the  reason  that  it  takes  too  much  time  to  accomplish  the 
desired  result.     By  forcible  divulsion  the  same  result  can  be 


Fig.  114.— Durham's  Rectal  Dilator. 

obtained  within  -five  minutes  and  the  patient  saved  much  time, 
sufifering,  and  expense. 

Forcible  Divulsion  of  a  stricture  should  be  done  under 
general  anesthesia.  It  may  be  accomplished  with  the  fingers, 
bougies,  the  author's  operating  speculum,  or  with  a  Durham, 
Whitehead,  or  other  mechanic  rectal  dilator  (Figs.  114  and 
115).  The  fingers  are  by  far  the  best  means  of  forcibly  stretch- 
ing a  stricture,  because  the  operator  can  readily  detect  any 
tearing  and  immediately  change  the  direction  of  pressure. 
When  mechanic  dilators  are  used,  extensive  damage  may  be 
done  before  the  operator  is  aware  of  it.  The  author  has  treated 
several  cases  of  fecal  incontinence  caused  in  this  way. 

There  are  many  forms  of  bougies  (Fig.  116).  Ordinarily 
the  writer  prefers  those  about  twelve  inches  (3.5  decimeters) 
long,  made  of  red  rubber  (Wales),  and  having  a  central  open- 
ing through  which  the  bowel  can  be  irrigated  with  water 
or    medicated    solutions    (Fig.    117).      They    are    to    be    had 


370  DISEASES  OF  THE  RECTUM  AND  ANUS 

in  various  sizes.  Allingham  uses  hollow,  vulcanized  tubes 
of  different  sizes  with  a  shield  to  prevent  them  from  slipping 
into  the  bowel.  For  the  purpose  of  dilating  the  stricture,  Mr. 
Cripps  has  made  bougies  of  twelve  sizes  with  a  slight  uniform 
taper  from  base  to  apex,  their  length  increasing  from  four  and 
a  half  inches  (11.4  centimeters)  in  No.  1  to  five  and  a  half  inches 
(13.9  centimeters)  in  No.  12.  .  The  diameter  at  the  base  in- 
creases from  one-fourth  of  an  inch  (6.3  millimeters)  to  one  and 
three-eighth  inches  (3.5  centimeters). 

It  is  rarely  necessary  to  have  the  bougie  retained  for  more 
than  a  few  moments ;  if,  however,  it  is  desired  to  keep  the 
dilator  in  position  for  some  time,  it  can  be  attached  to,  and 
held  in  place  by  means  of,  a  T-bandage.  Sponge  and  laminaria 
tents,  inserted  within  the  stricture  and  left  in  situ,  will  grad- 
ually dilate  the  constriction  and  prove  serviceable  in  some 
cases. 


Fig.  n5.— Whitehead's  Rectal  Dilator. 

Electrolysis. — Personally,  the  author  has  had  but  little  ex- 
perience with  this  method  of  treatment ;  but,  from  observa- 
tions he  has  made  of  its  use  by  others  in  the  treatment  of 
growths,  tumors,  and  cicatrices  in  other  portions  of  the  body, 
he  believes  that  very  little  good  can  be  accomplished  with  it 
alone.  He  is  of  the  opinion  that  nearly,  if  not  all,  surgeons 
will  concur  in  this  belief,  notwithstanding  the  fact  that  text- 
books on  electricity  assert  that  many  cures  can  be  secured  by 
its  proper  application.  Whitmore,  Earle,  and  Newman  have  all 
reported  cases  of  stricture  successfully  treated  by  electrolysis. 

The  treatment  of  stricture  of  the  rectum  by  electrolysis  is 
similar  to  that  used  for  stricture  of  the  urethra,  except  that  a 
stronger  current  (15  milliamperes)  may  be  used  in  the  bowel 
and  be  applied  more  frequently.  The  current  is  applied  by 
means  of  electrodes,  of  various  shapes  and  sizes,  introduced 
into  the  rectum  and  sometimes  within  the  constriction,  while 
the  other  pole  is  placed  upon  the  abdomen.     For  further  in- 


NON-MALIGNANT  STRICTURE  371 

formation  concerning  the  treatment  of  stricture  by  electrolysis 
the  reader  is  referred  to  standard  works  on  electrothera- 
peutics. 

Internal  Proctotomy. — This  procedure  consists  in  passing  a 
probe-pointed  bistoury  into  the  rectum  and  incising  the  strict- 
ure in  one  or  more  places,  as  the  case  demands.  When  the 
stricture  is  annular,  or  due  to  a  fibrous  band  stretching  across 
some  portion  of  the  bowel  within  two  inches  (5  centimeters) 
of  the  anus,  this  method  will  prove  efficient  in  many  cases,  pro- 
vided proper  attention  is  paid  to  the  after-treatment.  Internal 
division  of  stricture  is  generally  condemned,  because  of  the  fre- 
quent occurrence  of  sepsis,  abscesses,  and  fistula  following  the 
operation,  the  result  of  improper  drainage  There  is  also  the 
danger  of  concealed  hemorrhage.  Owing  to  these  dangers,  this 
operation  is  unsuitable  in  cases  in  which  a  considerable  portion 
of  the  bowel  is  constricted  and  ulcerated.  Koenig  recommends 
bloodless  gradual  dilatation  in  conjunction  with  incision  of  the 
stricture. 


£■  ^.  YAlVfVALC   CO.  "H'^A 

Fig.  116. — Set  of  "Aloes"  Hard-Rubber  Bougies. 

The  author  has  treated  by  internal  proctotomy  a  few  cases, 
uncomplicated  by  extensive  ulceration,  with  fair  success.  When 
accompanied  by  ulceration,  a  hollow  tube  or  a  piece  of  gauze 
should  be  left  in  the  rectum  after  the  operation  to  insure  per- 
fect drainage  and  to  guard-  against  concealed  hemorrhage. 

Posterior  Proctotomy  (External  Proctotomy;  Nelaton's  Opera- 
tion).—  This  operation  has  been  revived  and  popularized  by 
Verneuil,  of  Paris,  and  is  sometimes  given  the  name  of  linear, 
or  external,  proctotomy.  This  method  of  treating  stricture 
has  not  as  yet  been  received  with  much  favor  by  surgeons  in 
general,  but  it  is  gaining  friends  every  year.  Prominent  sur- 
geons— as  the  Allinghams  (senior  and  junior),  Van  Buren, 
Kelsey,  and  Cripps — advocate  it  as  the  best  operation,  except- 
ing colostomy,  in  cases  of  threatened  obstruction,  accompanied 
by  extensive  ulceration.  On  the  other  hand,  Mathews,  Crede, 
and  others  %\^t  preference  to  the  simple  internal  division  of 
the  stricture  at  different  points. 

Ouenu  and  Hartmann  have  collected  32  cases  of  stricture, 


372 


DISEASES  OF  THE  RECTUM  AND  ANUS 


including  6  of  their  own,  treated  by  external  proctotomy; 
but  1  patient  was  cured,  21  relapsed,  3  died  from  the  operation, 
and  4  died  at  a  later  period  from  cachexia  or  phthisis. 

In  the  author's  experience,  posterior  proctotomy  has  many 
advantages  over  the  internal  division  and  other  operations, 
and  is  a  most  valuable  substitute  for  colostomy  in  all  bad  cases 
of  non-malignant,  ulcerating  stricture.  The  advantages  of  poste- 
rior proctotomy  are  :  1.  It  permits  of  free  drainage  through  the 
deep  triangular  incision.  2.  Any  hemorrhage  that  might  occur 
can  be  readily  detected  and  arrested.  3.  It  allows  free  dis- 
charge of  accumulated  feces,  immediately  doing  away  with  all 


Fig.  n7.— Wales's  Soft-Rubber  Rectal  Bougies. 

Straining,  pain,  diarrhea,  and  tenesmus.  4.  It  permits  of  easy 
irrigation  and  medication  both  above  and  below  the  stricture. 
Technic.  —  The  operation  is  performed  as  follows :  With 
the  patient  in  the  lithotomy  position,  the  limbs  well  flexed  and 
held  in  position  by  means  of  a  Clover  crutch,  the  anus  and  sur- 
rounding parts  are  cleansed,  shaved,  and  the  rectum  irrigated. 
A  straight,  probe-pointed  bistoury  of  good  length  is  then 
selected,  placed  flat  upon  the  finger,  then  introduced  within 
the  anus  and  passed  upward  until  the  constriction  is  felt;  the 
knife  is  then  thrust  through  the  stricture  aperture  and  made 
to  pass  backward  to  or  near  the  sacrum.     It  is  then  withdrawn, 


NON-MALIGNANT  STRICTURE  373 

cutting  the  stricture  and  all  intervening  tissues,  including  the 
sphincters,  downward  and  outward  to  a  point  opposite  the  tip 
of  the  coccyx,  thus  making  a  long  and  deep  triangular  incision. 
If  on  examination  it  is  found  that  all  the  constriction  has  not 
been  severed,  the  incision  is  extended  or  deepened.  Bleeding 
is  then  arrested  by  ligating  all  spurting  vessels,  the  rectum  irri- 
gated with  1  to  5000  sublimate  solution,  the  incision  packed 
with  dry  iodoform  gauze,  and  the  patient  placed  in  bed  and 
given  V4  grain  (0.016  gram)  of  morphine  hypodermically  if 
suffering  much  pain. 

The  after-treatment  consists  in  daily  flushing  the  rectum 
with  any  reliable  antiseptic  or  medicated  solution.  The  dress- 
ing is  completed  by  the  insertion  of  dry  gauze  in  the  wound 
to  prevent  too  rapid  healing  and  to  assist  drainage.  When 
granulations  become  sluggish,  the  application  of  silver  nitrate 
or  balsam  of  Peru  will  prove  serviceable.  It  is  necessary  to 
pass  a  good-sized  bougie  from  time  to  time  for  several  weeks 
to  prevent  too  much  contraction. 

Excision.  —  Extirpation  of  the  strictured  portion  of  the 
bowel,  when  the  operation  is  successful  and  not  followed  by 
unpleasant  sequels,  is  the  most  effective  method  of  relieving 
stricture  of  the  rectum,  and  the  good  results  obtained  are  the 
most  permanent.  When  first  suggested,  much  was  expected 
from  this  operation  for  the  relief  of  stricture.  Experience  has 
proven,  however,  that  it  is  no  more  reliable  than  any  of  the 
operations  above  described,  owing  to  its  high  mortality  and 
the  frequent  occurrence  of  sepsis,  abscess,  and  fistula.  More- 
over, in  many  cases  the  sutures  uniting  the  bowel  and  skin  cut 
out,  allowing  the  gut  to  retract,  which  in  time  produces  a  sec- 
ondary stricture. 

Quenu  and  Hartmann  are  partial  to  this  operation.  How- 
ever, the  results  shown  in  35  cases  collected  by  them  are,  in 
the  writer's  opinion,  not  at  all  flattering  to  the  operation ;  out 
of  these  35  cases,  2  patients  died  from  the  operation,  1  a  short 
time  later,  and  a  fourth  died  indirectly  from  the  operation, 
making  a  mortality  of  11.43  per  cent. ;  of  the  remaining  31,  2 
patients  died  of  intercurrent  disease  and  10  were  lost  sight  of; 
of  the  19  others,  1  afterward  underwent  a  colostomy  for  re- 
lapse of  stricture.  The  remaining  18  suffered  from  proctitis 
with  suppurative  discharge ;  1  of  them  had  a  stercoral  fistula ; 
8   suffered  from   incontinence   of  gas   and  feces,   and   1   from 


374  DISEASES  OF  THE  RECTUM  AND  ANUS 

complete  incontinence ;  this  leaves  8  patients  who  had  natural 
stools  and  were  free  from  pain. 

Excision  is  more  suitable  as  a  secondary  operation  follow- 
ing colostomy  in  the  treatment  of  malignant  stricture  than  as 
a  method  of  relieving  benign  stricture.  The  strictured  portion 
of  the  bowel  may  be  removed  in  a  manner  similar  to  the  opera- 
tions described  in  the  chapter  on  cancer  of  the  rectum.  In 
other  words,  depending  upon  its  location  and  extent,  the 
strictured  section  of  the  gut  may  be  excised  by  either  the  so- 
called  perineal,  vaginal,  or  Kraske  route.  In  these  cases  every 
precaution  should  be  taken  to  prevent  injury  to  the  sphincter- 
muscle.  When  the  stricture  is  in  the  upper  rectum  or  sigmoid, 
the  strictured  portion  of  the  bowel  should  be  resected  and  an 
end-to-end  or  lateral  anastomosis  made. 

In  two  cases  of  stricture  located  in  the  anal  canal  the 
writer  amputated  the  bowel  just  above  the  constriction  and 
attached  the  end  of  the  gut  to  the  skin.  In  one  case  the  re- 
sult was  perfect.  In  the  other  case  the  sutures  sloughed  out 
and  the  bowel  retracted,  leaving  a  circular  band  of  ulceration 
which  required  months  to  heal;  a  well-marked  stricture  was 
left,  and  the  patient's  condition  was  almost  as  bad  as  when  he 
applied  for  treatment. 

Colostomy.— That  colostomy  is  the  best  operation  yet  de- 
vised for  the  immediate  and  permanent  relief  of  aggravated  non- 
malignant  stricture  cannot  be  denied.  It  has  been  the  writer's 
good  fortune,  in  many  instances,  to  see  patients — who  were 
almost  dead  from  exhaustion  resulting  from  incessant  diarrhea, 
tenesmus,  and  pain — rapidly  restored  to  comparatively  good 
health  and  usefulness  in  a  short  time  after  a  colostomy  had  been 
made.  After  colostomy  has  been  performed  any  impacted  feces 
in  the  colon,  sigmoid,  and  upper  part  of  the  rectum  can  be  dis- 
solved and  brought  away  by  copious  injections  of  water,  oil,  and 
Castile  soap.  After  this  all  the  feces  pass  out  at  the  artificial 
opening,  leaving  the  rectum  free  and  clean.  Any  ulceration 
present  can  be  made  to  heal  by  medicated  solutions  and  topic 
applications  introduced  through  both  the  rectum  and  the 
opening  in  the  groin  (Fig.  118).  The  benefit  at  once  becomes 
obvious.  In  case  the  ulceration  and  stricture  are  cured,  the 
opening  in  the  groin  can  be  closed.  The  surgeon  will  rarely 
be  called  upon  to  do  this,  because  in  many  cases  it  is  impossible 
to  cure  the  stricture,  and,  even  when  this  has  been  accom- 


NON-MALIGNANT  STRICTURE 


375 


pHshed,  patients  do  not  wish  to  take  any  chances  of  having  to 
go  through  their  former  suffering.  Most  of  them  go  about 
their  ordinary  duties  wearing  a  truss  similar  to  that  worn  for 
hernia,  and  say  that  the  artificial  anus  causes  them  very  little 
annoyance.  The  manner  of  performing  colostomy  is  discussed 
by  the  writer  in  another  chapter. 

Proctoplasty.  — ■  This  operation  is  suited  to  comparatively 
few  cases  of  stricture  of  the  rectum  because  of  the  ulceration 
and  indurated  condition  of  the  parts  in  aggravated  cases  of 


Fig.  118.— Showing  Applicator  Tassing  Through  Left  Inguinal  Colostomy 
Opening  and  Out  at  the  Anus  to  Show  the  Direct  Line  Between  these 
Points  and  also  the  Method  of  Making  Topic  Applications  to  the  Rectum 
from  Above. 


Stricture.  The  writer  has  resorted  to  proctoplasty  in  three 
cases,  with  the  following  results :  In  one  no  improvement  was 
perceptible ;  in  the  second  the  lumen  of  the  bowel  at  the  site 
of  the  constriction  was  materially  enlarged  and  the  patient  to 
a  great  degree  relieved ;  in  the  third,  because  of  the  thickened 
condition  of  the  bowel-wall,  it  was  difficult  to  close  the  incision, 
and  there  was  so  much  tension  upon  the  sutures  they  cut  out, 
the  wound  became  infected,  and  an  abscess  resulted  which  left 
a  sinus  extending  from  the  rectum  to  the  region  of  the  coccyx, 


376  DISEASES  OF  THE  RECTUM  AND  ANUS 

requiring  a  second  operation.  The  symptoms  for  the  reHef  of 
which  the  original  operation  was  made  were  not  reheved,  and 
the  patient  was  really  left  in  a  worse  condition  than  when  he 
applied  for  treatment. 

The  technic  of  the  operation  is  as  follows :  The  coccyx, 
and,  if  necessary,  part  of  the  sacrum,  are  removed  through  a 
long,  posterior,  median  incision;  the  rectum  is  then  freed  from 
its  attachments  by  means  of  the  finger  and  blunt  scissors;  a 
longitudinal  incision  of  sufficient  length  is  then  made  through 
the  posterior  rectal  wall  and  including  the  stricture;  by  grasp- 
ing the  bowel  at  both  ends  of  the  cut  and  bringing  them  to- 
gether, the  incision  is  brought  transverse  to  the  long  axis  of 
the  bowel,  where  it  is  sutured  in  a  manner  similar  to  that  in 
the  author's  proctoplasty  for  the  relief  of  procidentia  recti  (Figs, 
129  and  130).  The  external  wound  is  closed  with  catgut, 
leaving  a  drain  in  if  necessary;  dressings  are  applied  and  the 
patient  placed  in  bed.  When  the  stricture  is  complicated  by 
ulceration,  the  wound  within  the  bowel  should  be  protected  with 
iodoform  gauze. 

Bacon's  Operation. — Bacon  devised  the  operation  of  bring- 
ing the  sigmoid  colon  down  and  making  an  anastomosis  be- 
tween it  and  the  rectum  at  a  point  below  the  stricture,  thus 
forming  a  channel  for  the  passage  of  the  feces. 

The  technic  of  the  operation  is  as  follows :  With  the  pa- 
tient in  the  Trendelenburg  position,  the  rectum  and  sigmoid  are 
exposed  by  an  incision  extending  from  the  umbilicus  to  the 
pubes.  The  location  and  extent  of  the  constriction  is  noted 
and  the  proper  point  determined  upon  for  the  anastomosis. 
The  sigmoid  colon  is  then  opened  and  the  male  segment  of  a 
Murphy  button  is  inserted  and  secured  in  place ;  the  other  seg- 
ment of  the  button  is  carried  up  through  the  anus  by  means  of 
a  specially  devised  trocar,  with  which  the  bowel  is  punctured, 
and  the  shank  of  the  button  inserted  at  the  point  determined 
upon  for  the  anastomosis.  The  button  is  then  locked  and  a  few 
supplementary  sutures  inserted  to  prevent  hernia  of  the  small 
intestine;  after  which  the  abdominal  incision  is  closed.  After 
the  button  has  been  discharged,  the  spur  formed  by  the  walls 
of  the  rectum  and  sigmoid  which  are  in  apposition  are  clamped 
with  strong  forceps,  one  blade  being  introduced  through  the 
opening  made  by  the  button  and  the  other  through  the  strict- 
ured  aperture.    The  clamp  is  then  tightened  each  day  until  the 


NON-MALIGNANT  STRICTURE  377 

partition  (spur)  is  destroyed,  thus  completing  the  communica- 
tion between  the  rectum  and  sigmoid. 

The  above  operation  is  not  suited  for  the  treatment  of 
stricture  situated  below  the  internal  sphincter.  In  order  to  relieve 
this  latter  class  of  constrictions  Bacon  proceeds  as  follows:  An 
aneurismal  needle  threaded  with  silk  is  forced  through  the 
rectal  wall  and  then  carried  backward  and  upward  until  it  can 
be  pushed  through  the  rectum  just  above  the  stricture.  The 
Hgature  is  then  puhed  down  through  the  constriction  with 
forceps  and  the  two  ends  tied  and  left  hanging  loosely  outside 
the  anus.  The  thread  is  not  adjusted  tightly  around  the  strict- 
ure, as  it  is  necessary  to  leave  the  seaton  in  place  for  some 
time  to  establish  a  continuous  mucous  tract.  Three  months 
later  a  grooved  director  is  passed  through  the  sinus  posterior 
to  the  stricture  and  the  intervening  stricture  is  divided.  The 
special  advantage  claimed  for  this  operation  is  that  the  tract 
formed  by  the  seaton  prevents  closure  of  the  wound  after  the 
stricture  has  been  cut  as  is  so  frequently  the  case  after  poste- 
rior proctotomy. 

ILLUSTRATIVE   CASES 
Case  XIX.    Stricture  Due  to  Muscular  Band  (Internal  Proctotomy).— A 

lady,  aged  27  years,  who  had  been  suffering  from  stricture  of  the  rectum  for 
two  years,  complained  of  the  ordinary  symptoms,  except  ulceration.  Exami- 
nation revealed  the  presence  of  a  narrow,  circular  band,  one-fourth  of 
an  inch  (6.3  millimeters)  in  thickness,  about  one  and  a  half  inches  (3.8 
centimeters)  above  the  anus,  extending  entirely  around  the  rectum.  This 
was  divided  behind,  before,  and  on  both  sides,  and  the  rectum  cleansed.  The 
after-treatment  consisted  in  passing  a  bougie  (full  sized)  twice  a  week  for 
two  months,  when  she  was  discharged  cured.  Several  months  afterward  she 
reported  that  she  was  entirely  relieved. 

Case  XX.  Stricture  of  the  Rectum  (Posterior  Proctotomy).— Male,  aged 
40;  father  of  a  large  family;  history  of  syphilis;  had  no  bad  habits  except 
inveterate  smoking.  Several  months  previous  to  the  time  he  came  under  my 
care  he  was  troubled  with  constipation,  but  could  obtain  relief  from  large 
doses  of  castor-oil  and  Epsom  salts.  Later,  constipation  became  worse  and 
the  fecal  discharges  were  mixed  with  pus,  blood,  and  mucus.  He  had  frequent 
pains  in  the  pelvis,  up  the  back,  and  down  the  limbs,  and  his  complexion  was 
muddy.  He  had  become  ill  tempered  and  despondent.  The  strongest  purga- 
tives failed  to  give  relief,  except  when  assisted  by  copious  injections  of  water 
and  glycerin,  and  when  the  stool  did  come  it  was  ribbon-like  and  never  of 
natural  formation.  At  this  time  constipation  began  to  alternate  with  diar- 
rhea, and  nothing  could  pass  the  constriction  unless  it  was  fluid  or  semisolid. 
The  patient  spent  a  large  part  of  his  time  in  the  closet  straining,  never  getting 
any   satisfaction,    always    feeling   that    the    bowel   had   not   been   completely 


378  DISEASES  OF  THE  RECTUM  AND  ANUS 

emptied.  He  went  from  one  physician  to  another,  each  treating  him  for 
chronic  diarrhea.  He  was  treated  for  six  months  by  electricity  without  the 
slightest  benefit,  the  symptoms  in  the  meantime  becoming  more  and  more 
exaggerated  until  immediate  obstruction  was  threatened.  Then  the  family 
physician  was  called;  he  made  a  digital  examination  and  discovered  a  strict- 
ure, two  and  a  half  inches  (6.4  centimeters)  above  the  anus,  which  was  so 
tight  that  the  smallest-sized  rectal  bougie  would  not  enter  it.  I  was  then 
called  in  to  make  an  examination.  By  palpation  I  found  that  the  sigmoid 
and  the  descending  colon  were  filled  with  impacted  feces.  A  posterior  proc- 
totomy was  decided  upon.  A  proctotomy-knife  was  passed  through  the  con- 
striction and  then  backward  until  its  point  came  into  contact  with  the  bony 
structures,  then  downward  and  outward  to  the  tip  of  the  coccyx,  including 
the  sphincters.  All  ulcers,  both  above  and  below  the  stricture,  were  curetted, 
and  a  silver  solution  applied.  The  after-treatment  was  carried  out  as  previ- 
ously outlined.  Two  Aveeks  from  the  time  the  operation  was  performed  the 
patient  left  the  hospital  and  came  to  my  office  twice  a  week  to  have  the  bougie 
passed.  At  the  end  of  the  sixth  week  he  was  perfectly  comfortable  and  went 
on  the  road  as  commercial  traveler,  armed  with  a  No.  12  Wales  bougie,  which 
he  passes  from  time  to  time. 

Case  XXI.  Stricture  of  the  Rectum,  with  Almost  Complete  Obstruction 
(Colostomy). — Mrs.  A.  was  referred  to  me  by  Dr.  B.  to  be  treated  for  stricture 
of  the  rectum.  She  gave  the  following  history:  She  was  30  years  old,  her 
family  history  was  good,  and  there  was  no  positive  evidence  that  she  had 
syphilis,  though  her  husband  was  at  that  time  being  treated  for  this  disease. 
She  first  noticed  there  was  something  the  matter  with  the  rectum  two  years 
before  I  saw  her,  when  she  had  a  hemorrhage  from  the  anus  following  an 
attack  of  constipation.  After  this  constipation  became  worse ;  the  feces  were 
not  natural  in  form,  but  were  small,  nodular,  or  soft  and  ribbon-like;  and 
were  expelled  with  difficulty,  pain,  and  straining.  Later,  diarrhea  predomi- 
nated, forcing  her  to  spend  the  major  portion  of  her  time  in  the  closet  en- 
deavoring to  empty  the  bowel.  The  liquid  portion  of  the  feces  was  readily 
discharged,  but  the  solid  portion  remained.  The  feces  were  streaked  with 
blood  or  pus ;   in  brief,  she  had  all  the  symptoms  of  stricture  of  the  rectum. 

On  digital  examination  a  stricture  Avas  detected  two  and  one-half  inches 
(6.4  centimeters)  above  the  anus,  the  edges  of  which  were  ulcerated;  the 
whole  rectum  was  saturated  with  a  foul  discharge.  The  constriction  was  so 
tight  that  a  No.  4  Wales  bougie  would  not  pass  it.  I  warned  her  of  the 
danger  of  obstruction,  it  now  being  six  weeks  since  she  had  passed  any  solid 
feces,  and  the  colon  and  sigmoid  were  packed  with  them.  Colostomy  was  ad- 
vised and  she  declined.  Instead  I  performed  linear  proctotomy,  but  told  her 
the  relief  would  be  only  temporary.  For  three  months  she  did  well.  At  the 
end  of  one  year,  however,  she  came  back,  and  said  she  was  willing  to  have  the 
other  operation  performed,  if  it  would  give  her  permanent  relief  from  the 
pain  and  straining. 

Operation. — An  incision  was  made,  one  and  one-half  inches  (3.8  centi- 
meters) long,  a  little  above  and  two  inches  (5  centimeters)  to  the  inner  side 
of  the  anterior  spine  of  the  ilium;  the  peritoneum  was  opened  and  stitched 
to  the  skin.  The  descending  colon  was  located  without  difficulty  and  brought 
outside.     The  mesentery  being  long,  it  was  thought  best  to  remove  a  con- 


NON-MALIGNANT  STRICTURE  379 

siderable  portion  of  the  colon  to  prevent  prolapse.  Accordingly,  the  gut  wa3 
pulled  out  until  taut.  This  brought  about  eight  inches  (2  decimeters)  of 
gut  on  the  outside  of  the  abdomen.  A  supportive  stitch  v/as  then  passed 
through  the  mesentery  near  the  gut  on  one  side  of  the  loop,  and  the  same 
way  on  the  other,  thus  including  all  the  mesentery;  it  was  then  passed  back 
through  the  skin  of  the  same  side  and  tied.  The  two  portions  of  the  gut  form- 
ing the  loop  were  thus  brought  into  contact.  This  insured  a  good  spur. 
Several  interrupted  sutures  were  taken  to  fasten  the  intestine  to  the  ab- 
dominal wall.  The  dressing  consisted  in  covering  the  gut  and  abdomen  with 
oil-silk  smeared  with  vaselin;  over  this  iodoform  gauze  and  cotton,  which 
were  held  in  place  by  a  snug  bandage. 

The  patient  was  put  to  bed  and  recovered  from  the  anesthetic  in  half  an 
hour,  suftering  but  little  pain.  I  did  not  see  her  again  until  11  o'clock  at 
night:  some  eight  hours  after  the  operation.  The  nurse  informed  me  that 
she  had  been  vomiting,  but  otherwise  had  been  very  comfortable.  I  make 
it  a  rule  in  all  colostomy  cases  to  remove  the  bandage  each  time  I  see  the 


Fig.  119. — Appearance  of  Gut  Before  Removal. 

patient,  to  be  certain  all  is  well.  When  I  did  so  in  this  case  the  abdomen  was 
found  covered  with  coils  of  small  intestines  which  had  slipped  out  beside  the 
colon,  where  a  stitch  had  given  way.  They  were  still  warm,  for  the  reason 
that  the  oil-silk  had  retained  the  heat.  They  were  immediately  bathed  with 
carbolized  Avater,  replaced,  and  the  opening  packed  with  gauze  to  prevent  a 
recurrence  of  the  prolapse.  The  next  morning  her  pulse  and  temperature  were 
normal  and  continued  so  until  she  was  discharged.  The  first  two  days  she 
suffered  some  from  gas,  but  received  immediate  relief  on  the  third  day,  when 
that  portion  of  the  colon  outside  the  abdomen  (Fig.  119)  was  removed. 

From  this  time  on  her  recovery  was  uninterrupted,  but  was  delayed  some- 
what on  account  of  retraction  of  the  gut.  One  year  after  the  operation  she 
was  perfectly  comfortable,  her  bowel  acted  but  once  a  day,  and  the  ulceration 
was  gradually  healed  by  local  applications  applied  both  from  above  and  below. 
This  case  is  reported  to  call  attention  to  the  importance  of  removing 
the  bandage  frequently  to  see  that  none  of  the  intestines  protrude,  for  there 
is  no  doubt  in  my  mind  but  that  this  patient's  life  was  saved  by  this  pre- 
caution.   The  accompanying  illustrations  show  the  appearance  of  the  gut  be- 


380 


DISEASES  OF  THE  EECTUM  AND  ANUS 


fore  it  was  excised  and  of  the  artificial  anus  at  the  present  time.  The  lower 
opening  is  almost  closed,  and  the  upper  very  much  reduced  in  size,  due  to 
vicious  cicatrization  (Fig.  120),  which  so  often  follows  operations  on  negroes. 

Case  XXII.  Stricture  of  the  Rectum  (External  Proctotomy). — Mr.  S.  W. 
came  to  me  suffering  from  the  usual  symptoms  of  stricture  of  the  rectum: 
diarrhea,  straining  at  stool,  reflected  pains,  etc.  Digital  examination  revealed 
the  presence  of  a  well-marked  stricture  located  two  inches  (5  centimeters) 
above  the  anus  and  which  appeared  to  be  caused  by  scar-tissue.  It  was  so 
tight  that  the  end  of  the  index  finger  could  not  be  passed  through  it.  Im- 
mediately below  the  constriction  the  rectum  was  ragged  and  indurated  from 
ulceration. 

Treatment. — It  was  thought  best  to  perform  a  posterior  proctotomy. 
The  patient  was  anesthetized  and  placed  in  the  lithotomy  position,  and  the  rec- 
tum irrigated.     A  probe-pointed  bistoury  was  guided  to  the  strictured  point 


Fig.  120.— Artificial  Anus  One  Year  After  Operation,   Showing  Contraction   from 
Scars  Around  the  Opening  which  Caused  Partial  Obstruction. 


by  the  finger,  then  passed  up  until  Avell  above  it,  and  drawn  backward  and 
downward  to  the  tip  of  the  coccyx.  This  left  a  deep,  triangular  wound,  which 
readily  admitted  the  hand.  The  incision  was  followed  by  a  gush  of  blood, 
which  continued  to  flow  freely  until  the  ulcerated  spots  had  been  curetted  and 
the  rectum  tightly  packed  with  gauze,  and  cotton  placed  over  this  and  sup- 
ported by  a  T-bandage.  The  after-treatment  consisted  in  daily  irrigations, 
after  which  the  wound  was  loosely  packed  with  gauze.  Every  other  day  a 
No.  12  Wales  bougie  was  passed  to  prevent  contractions  to  any  considerable 
degree.  After  the  first  week  he  had  no  pain,  and  the  annoying  symptoms  had 
disappeared.  At  the  end  of  the  month  he  left  the  hospital,  able  to  retain 
feces,  and  was  having  but  one  well-foi-med  motion  daily.  He  was  instructed 
to  pass  a  bougie  regularly  twice  a  week. 

Case  XXIII.  Stricture  Due  to  Fibrous  Band  (Gradual  Tivulsion) .— Miss 
L.  was  referred  to  me  by  a  neighboring  physician  to  be  treated  for  stricture. 
She   had  the  usual  symptoms.     A  constriction   was  located  one   and  a   half 


NON-MALIGNANT  STRICTURE  381 

inches  (3.8  centimeters)  up  the  bowel,  but  there  was  no  ulceration.  The 
occlusion  was  caused  by  a  thin,  fibrous  band,  half  an  inch  (1.27  centimeters) 
in  width,  which  extended  two-thirds  of  the  way  around  the  bowel. 

Treatment. — This  was  thought  to  be  a  suitable  case  for  gradual  dilata- 
tion, as  the  young  lady  was  in  no  hurry  and  preferred  this  method  to  a  more 
radical  one.  She  was  instructed  to  call  at  my  office  every  other  day.  On  the 
first  day  a  No.  6  Wales  bougie  was  passed  with  some  little  difficulty;  at  the 
end  of  the  first  week  a  No.  8  could  be  introduced  and  at  the  end  of  the  third 
week  a  No.  10.  By  this  time  she  was  much  relieved  and  was  having  but  one 
action  daily,  and  that  with"  very  little  inconvenience.  Six  weeks  from  the 
time  the  treatment  was  begun  I  could  easily  pass  a  No.  12  bougie,  the  largest 
size,  without  causing  acute  pain.  There  were  no  further  symptoms  of  strict- 
ure, and  she  was  discharged  feeling  perfectly  well. 


LITERATURE  ON  STRICTURE  OF  THE  RECTUM  AND  ANUS 


Allingham:    "Cases  of  Stricture  and  Ulceration,"  "Diseases  of  the  Rectum  and 

Anus,"  p.  278,  1888. 
Bacon:    Jour.  Amer.  Med.  Assoc,  xxxiii,  p.  717,  1899. 

Ball:    "Diff'erential  Diagnosis  of  Stricture,"  "Rectum  and  Anus,"  p.  169,  1887. 
Bullard,  W.  Duff:    "Non-malignant  Stricture,"  Med.  Record,  Jan.  13,  1900. 
Carroll:    "Stricture,"  etc..  Trans.  Acad.  Med.  Cincinnati,  p.  102,  1897. 
Cripps:    "Non-malignant  Stricture,"  "Diseases  of  the  Rectum  and  Anus,"  pp. 

223,  244,  1890. 
Fournier:    "Lesions  Tertiares  de  I'Anus  et  Rectum."     Paris,  1875. 
Fraenkel:    MiincJiener  med.  Woclien.,  xlvii,  p.  5.57,  1895. 
Halstead:    "Non-malignant  Stricture,"  N.  T.  Med.  Neics,  Ixxiii,  p.  37,  1898. 
Holmes:    "Stricture,"  etc.,  Dom.  Med.  Monthly,  Toronto,  p.  189,  1898. 
Kelsey:    "Non-malignant  Stricture,"  "Diseases  of  the  Rectum  and  Anus,"  p. 

345,  1890. 
Koenig:    "Lehrbuch  d.  spec.  Chirurgie,"  Bd.  ii,  p.  551,  1899. 
Krause:    "Stricture  of  Rectum,"  Cincinnati  Lancet-Clinic,  xliv,  1900. 
Leichtenstern:    "Ziemssen's  Cyclopedia,"  vol.  vii,  p.  484,  1876. 
Mathews:     "Non-malignant   Stricture,"  "Diseases   of  the  Rectum,  Anus,  and 

Sigmoid  Flexure"  (first  edition),  pp.  336-365,  1896. 
Quenu  and  Hartmann:    "Stricture,"  etc.,  "Chirurgie  du  Rectum."    Paris,  1895. 
Rieder :    "Pathology  of  Stricture  of  the  Rectum,"  A7'ch.  f.  Uin.  Chir.,  xv,  p.  730, 

1873. 
Sonnenberg:    "Stricture,"  etc.,  Berliner  Uin.  Woclien.,  xxxiv,  p.  737,  1897. 
Stewart:    Canadian  Lancet,  Toronto,  xxiv,  p.  121,  1896. 
Van  Buren:    "Phantom  Stricture,"  Awier.  Jour.  Med.  Sci.,  Oct.,  1897. 
Whitmore:    "Electrolysis,"  "Annual  of  the  Universal  Medical  Sciences,"  v,  p. 

61,  1888. 
Wood:    "Stricture,"  etc.,  Intercolonial  Med.  Jour.,  Australia,  iii,  p.  29,  1889. 


CHAPTER  XXV 

PROLAPSE  (PROCIDENTIA  RECTI,  PROLAPSUS  ANI) 

Prolapse  of  the  rectum  signifies  the  descent  through  the 
anus  of  a  portion  of  the  bowel  which,  under  normal  condi- 
tions, belongs  above  it  (Fig.  121).  This  condition  is  frequently 
called  "prolapsus  ani."  This  designation,  however,  is  incor- 
rect, because  the  anus  is  simply  an  aperture  capable  of  being 
everted,  but  not  prolapsed. 


Fig.  121.— Diagrammatic  Drawing  Sliowing  Prolapse  of  the  Rectum. 

Protrusion  of  the  mucous  membrane  alone  is  designated 
as  partial  prolapse,  and  descent  of  all  the  rectal  coats  is  termed 
complete  prolapse  (Plate  XXI).  Procidentia  recti  is  common 
to  both  sexes,  all  ages,  climates,  and  vocations;  but  is  most 
frequently  encountered  in  old  people  and  children  and  more 
often  in  women  than  in  men.  Indeed,  in  children  proci- 
dentia is  the  most  common  of  all  the  lesions  met  with  in  the 
ano-rectal  region. 

The  protrusions  are  variable  in  size,  soft  and  pliable  in 
consistence,  and  velvety  to  the  touch.     They  have  a  pyriform 
shape,  and  present  a  slit  in  their  distal  end. 
(382) 


feg 
o 


X' 


PROLAPSE 


383 


ETIOLOGY 

In  children  the  most  common  causes  of  prolapse  are  diar- 
rhea, constipation,  phimosis,  whooping-cough,  lack  of  the 
pelvic  musculature,  and  absence  of  the  sacral  curve,  or,  in  fact, 
anything  which  excites  frequent  stools  or  causes  undue  strain- 
ing. 

In  adults  this  condition  may  be  induced  by  stone  in  the 
bladder,  enlarged  prostate,  fecal  impaction,  proctitis,  entero- 
liths, polyps,  tumors  of  the  bladder  or  vaginal  wall,  uterine 
procidentia,  or  any  other  condition  tending  to  drag  the  bowel 
downward  during  defecation. 


Fig.  122.— Prolapse  of  the  Mucous  Membrane  (Partial  Procidentia). 


The  Upright  posture  assumed  by  man  undoubtedly  plays 
an  important  role  in  the  production  of  this  condition,  especially 
where  lack  of  tonicity  and  partial  or  complete  paralysis  of  the 
rectum  co-exist. 

Inflammatory  exudations  in  the  submucosa  may  cause 
procidentia.  In  order  to  demonstrate  this  mode  of  origin 
Molliere^  inserted  a  blow-pipe  beneath  the  rectal  mucous  mem- 
brane in  the  cadaver,  and,  by  inflation,  produced  an  artificial 
prolapse. 


1  "Maladies  du  Rectum,"  Molliere,  page  199,  1877. 


384 


DISEASES  OF  THE  KECTUM  AND  ANUS 


This  condition  is  sometimes  caused  by  sodomy  and  large 
sacro-coccygeal  tumors. 

PATHOLOGY 

In  procidentia  there  are  usually  present  a  lack  of  tonicity 
and  a  general  relaxation  of  the  muscles,  tendons,  and  fasciae 
which  support  the  pelvic  floor.  With  each  repetition  this  con- 
dition is  aggravated,  and  in  cases  of  long  standing  the  struct- 
ures mentioned  become  atrophied,  and  the  bowel,  lacking 
proper  support,  remains  below  the  anus  the  greater  part  of 
the  time. 

Eventually,  owing  to  the  constant  irritation  caused  by 
defecation,  exercise,  and  frequent  handling,  the  bowel  becomes 
thickened,  indurated,  and  ulcerated,  causing  occasional  hem- 


Fig.  123.— Partial  Prolapse  in  Young  Man  (Aged  18  Years). 


orrhages,  the  amount  of  bleeding  depending  upon  the  size  of 
the  vessels  involved.  In  aggravated  cases  there  are  also  pres- 
ent free  discharge  of  pus  and  increased  secretion  of  mucus. 

Because  of  the  frequent  stretching  by  the  protruded  mass, 
the  sphincter-muscle,  in  the  majority  of  cases,  loses  its  tonicity, 
and  becomes  relaxed  or  totally  paralyzed.  Before  this  condi- 
tion is  brought  about,  however,  the  sphincter,  as  a  result  of 
irritation,  sometimes  contracts  around  the  bowel,  preventing  a 
return  of  blood  and  eventuating  in  sloughing  of  the  projected 
bowel. 

In  cases  where  the  bowel  returns  spontaneously  or  re- 
mains above  the  muscle  when  replaced  by  the  mother  or  an 
attendant,  about  the  only  change  noticeable  in  its  appearance 
is  a  slight  redness  and  erosion  of  the  mucous  membrane. 


PROLAPSE 


385 


CLASSIFICATION 

There  are  many  and  varying  degrees  of  procidentia  recti, 
but  for  clinic  purposes  it  may  be  considered  as  occurring  in 
three  degrees : — 

1.  Prolapse  of  the  mucous  membrane  alone. 

2.  Prolapse  of  all  the  rectal  coats  and  sometimes  includ- 
ing a  part  of  the  smaH  intestine  (hernia  recti). 

3.  Prolapse  of  the  colon,  sigmoid,  or  upper  rectum  into 
the  lower  rectum,  called  invagination. 


Fig.  124. — Typic  Case  of  Extensive  Complete  Procidentia  Recti  in  Boy 
Three  Years  Old  (Congenital). 


Prolapse  of  the  Mucous  Membrane  (Partial  Procidentia). — 
This  is  the  most  common  form  of  prolapse.  It  is  usually  met 
with  in  children  between  one  and  five  years  of  age,  suffering 
from  summer  diarrhea,  whooping-cough,  phimosis,  or  difficult 
micturition.  It  comes  on  suddenly  after  a  strain  as  the  result 
of  detachment  of  the  mucous  membrane  from  its  bed,  which 
permits  it  to  slide  down  and  out  at  the  anus  (Figs.  122  and  123). 

The  protrusion  is  usually  small,  being  about  one  or  two 
inches  (2.54  or  5.08  centimeters)  in  length,  highly  colored,  and 
returns  either  spontaneously  or  by  the  aid  of  slight  pressure. 
Unless  the  exciting  cause  is  removed,  repeated  protrusions, 

25 


386 


DISEASES  OF  THE  RECTUM  AND  ANUS 


becoming  more  extensive  as  the  child  grows  older,  are  to  be 
expected. 

Prolapse   of  All  the   Rectal   Coats    (Complete   Procidentia) 

Protrusion  of  all  the  rectal  coats  (Figs.  124,  125,  and  126), 
alone  or  in  conjunction,  occurs  less  frequently  than  the  pre- 
ceding variety,  and  may  be  the  result  of  an  antecedent  partial 
prolapse  which  has  existed  for  a  number  of  years.  It  is  seen 
most  frequently  in  persons  past  middle  life  and  in  those  suffer- 
ing from  paralysis,  fecal  impaction,  vesic  calculi,  urethral  strict- 
ure, enlarged  prostate,  hemorrhoids,  or  polyps.    Women  suffer 


Fig.  125.— Typic  Case  of  Extensive  Complete  Procidentia  Recti  in  Boy  Three 
Years  Old  (same  as  Pig.  124;  Different  Position). 

from  it  more  than  men,  because  of  uterine  procidentia  and  the 
downward  dragging  of  the  bowel  by  the  head  of  the  child 
during  labor. 

The  protruded  mass  is  much  larger  than  in  the  variety 
previously  described,  measuring  from  three  to  six  inches  (7.62 
to  15.24  centimeters)  or  more  in  length  (see  Dr.  Ladinski's 
case,  Plate  XX  and  Fig.  126)  and  from  two  to  three  inches 
(5.08  to  7.62  centimeters)  across  the  base.  The  mucous  mem- 
brane and  other  coats  convey  to  the  touch  a  sensation  of  thick- 
ness and  firmness  not  elicited  in  protrusion  of  the  membrane 


PKOLAPSE 


387 


alone,  and  it  may  assume  enormous  proportions,  including  the 
upper  rectum,  sigmoid,  and  a  large  part  of  the  colon,  to  say 
nothing  of  the  peritoneum  and  loops  of  the  small  intestine. 

Prolapse  of  the  Colon,  Sigmoid,  or  Upper  Rectum  into  the  Lower 
Rectum  (Invagination ,  Intussusception) .  —  This  condition  is  of 
rare  occurrence  and  is  frequently  overlooked.  It  consists  in 
the  telescoping  of  a  portion  of  the  bowel  through  that  imme- 
diately below  it.  In  the  first  and  second  varieties  of  procidentia 
a  portion  of  the  lower  rectum  shps  down  and  out  through  the 
anus,  while  in  this  variety  the  lower  rectum  retains  its  normal 
position  and  the  bowel  above  is  telescoped  through  it.     In  ex- 


Fig.  126.— Case  of  Complete  Procidentia  Recti  Complicated  by  Stricture  in  a 
Woman  (same  as  Plate  XXI;  Different  Position). 

ceptional  cases  the  sigmoid  or  colon  my  be  invaginated  into  the 
rectum  without  protruding  from  the  anus. 

Out  of  220  cases  of  invagination  collected  by  Leichten- 
stern,  in  41  the  tumor  projected  from  the  anus,  and  in  31  other 
cases  it  was  felt  in  the  rectum.  These  statistics  give  a  fair  idea 
of  the  frequency  of  this  condition  in  the  lower  bowel. 

DIAGNOSIS 

Partial  procidentia  can  be  distinguished  from  the  complete 
variety  by  its  smaller  size,  brilliant  color,  the  thinness  and 
smoothness  of  the  membrane  composing  it,  the  tendency  to 


388  DISEASES  OF  THE  RECTUM  AND  ANUS 

return,  the  sudden  onset  after  straining,  and  also  by  the  fact 
that  it  is  more  frequently  met  with,  usually  occurring  in  infants 
and  young  children. 

Invagination  resembles  in  many  respects  prolapse  of  the 
rectum.  The  distinguishing  feature  is  that  below  its  origin 
the  rectal  wall  remains  intact,  while  the  bowel  is  being  tele- 
scoped through  it.  By  inserting  the  finger  into  the  rectum  a 
deep  sulcus  is  felt  entirely  around  and  between  the  annular 
ring  and  the  protruding  mass.  When  the  invagination  begins 
in  the  middle  rectum,  the  bowel  can  be  felt  dipping  over  the 
finger. 

When  loops  of  the  small  intestine  descend  with  the  pro- 
trusion (rectal  hernia),  they  will  invariably  be  found  in  its 
anterior  half,  and  are  readily  recognized  by  the  gurgling  sound 
and  impulse  on  coughing  which  may  be  felt  through  the  rectal 
wall.  In  such  cases  the  slit  in  the  distal  end  of  the  protrusion 
points  backward  toward  the  coccyx. 

When  the  diagnosis  is  doubtful,  invagination  of  the  rectum 
or  sigmoid,  which  does  not  protrude,  can  easily  be  seen  by 
means  of  the  proctoscope. 

Procidentia  Recti  has  been  mistaken  for  polyps,  hemor- 
rhoids, and  malignant  growths.  If  a  careful  examination  is 
made,  however,  such  an  error  is  easily  avoided.  Polyps  are 
usually  single,  bell-clapper  shaped,  and  have  a  long,  slender 
attachment. 

Hemorrhoids  can  easily  be  distinguished  from  prolapse,  be- 
cause the  latter  involves  the  entire  circumference  of  the  bowel, 
is  cone  shaped,  much  larger,  and  has  a  slit  in  the  center.  Piles, 
on  the  other  hand,  are  single  or  multiple,  and  appear  as  dark- 
bluish,  thick,  segmented  tumors,  the  individual  attachments  o( 
which  are  readily  seen,  and  the  mucous  membrane  between 
them  normal. 

Moreover,  when  there  is  a  protrusion  of  piles,  or  polyps, 
the  feces  are  evacuated  from  the  side  of  the  aperture,  while 
in  prolapse  they  are  discharged  through  the  center  of  the  pro- 
truding mass. 

Malignant  Growths  appear  in  the  rectum  as  hard,  nodular 
masses  or  cauliflower-like  excrescences,  and  protrude  only 
when  forced  forward  by  an  enormous  accumulation  of  feces, 
which  is  usually  recognizable  by  palpation  through  the  ab- 
dominal wall. 


PKOLAPSE  389 

SYMPTOMS 

In  recent  and  mild  cases  the  protrusion  consists  of  a  ring 
of  mucous  membrane,  one  or  two  inches  (2.54  to  5.08  centime- 
ters) in  length,  marked  by  crescentic  folds,  which  comes  down 
during  defecation,  completely  hiding  the  anus  from  view.  In 
the  beginning  the  tumor  is  of  a  reddish  tint  and  returns  spon- 
taneously. After  many  repetitions  the  mass  becomes  larger, 
is  congested,  bluish  in  color,  covered  with  abrasions,  sometimes 
strangulated,  remains  out  longer,  and  must  be  replaced  by  an 
attendant,  after  which  it  is  held  in  by  the  sphincter-muscle. 

In  complete  procidentia  the  bowel  remains  out  most  of  the 
time.  Because  of  this  and  the  large  amount  of  bowel  pro- 
truded, the  sphincter-muscle  becomes  worn  out  or  paralyzed, 
producing  the  typic  patulous  anus  and  sometimes  incontinence. 
As  a  result  of  frequent  handling  and  irritation,  the  mucous 
membrane  becomes  eroded  and  ulcerated ;  it  is  sensitive  when 
touched,  bleeds  from  the  slightest  insult,  and  is  bathed  in  a 
tenacious  mucus  and  pus.  Except  when  ulceration  or  partial 
or  complete  strangulation  exist,  these  patients  suffer  little  pain, 
but  they  do  complain  of  a  dragging  down  sensation. 

Gangrene  sometimes  occurs  as  a  result  of  strangulation, 
and  has  been  known  to  amputate  the  protruding  bowel.  In 
less  serious  cases  the  inflammation  is  accompanied  by  frequent 
stools  and  the  discharge  of  enormous  quantities  of  mucus. 

The  symptoms  induced  by  an  invagination  protruding 
through  the  anus  do  not  differ  materially  from  those  caused 
by  complete  procidentia.  In  those  cases  where  the  sigmoid 
or  the  upper  rectum  becomes  invaginated  into  the  lower  bowel, 
but  does  not  protrude,  the  principal  manifestations  are  sensa- 
tions of  weight  and  fullness,  tenesmus,  and  a  feeling  of  some- 
thing in  the  rectum  which  should  be  evacuated.  When  the 
invagination  is  extensive,  it  causes  frequent  mucoid  discharges; 
dull,  aching  pain  in  the  back ;  and  sometimes  vesic  disturb- 
ances. 

The  complications  of  complete  procidentia  are  occasionally 
dangerous.  The  most  frequent  causes  of  death  are  peritonitis 
and  rupture  of  the  rectal  wall,  accompanied  by  protrusion  of 
loops  of  the  small  intestines  (hernia  recti) :  a  condition  usually 
induced  by  heavy  lifting  or  great  straining. 


390  DISEASES  OF  THE  RECTUM  AND  ANUS 

PROGNOSIS 

In  giving  a  prognosis  in  cases  of  rectal  prolapse,  it  should 
be  borne  in  mind  that  in  young  children  a  spontaneous  cure 
of  partial  procidentia  sometimes  occurs  as  they  grow  older. 
In  the  majority  of  such  cases,  however,  some  form  of  treat- 
ment is  necessary  for  relief. 

In  cases  of  long  standing  (complete  procidentia),  where 
the  bowel  is  thickened  and  ulcerated,  nothing  short  of  pro- 
longed, vigorous  medical  treatment  or  a  surgical  operation  will 
effect  a  cure. 

Life  is  endangered  only  when  there  is  involvement  of  the 
peritoneum  or  small  intestine  and  when  there  is  complete 
strangulation  or  rupture  of  the  bowel. 

TREATMENT 

The  treatment  to  be  carried  out  in  cases  of  procidentia 
recti  is  non-operatwe  or  surgical,  depending  upon  the  cause, 
extent,  and  duration;  condition  of  the  bowel;  and  whether  the 
protrusion  is  constant  or  retains  its  position  when  returned  above 
the  sphincter. 

NON=OPERATIVE   TREATMENT 

Non-operative  treatment  should  be  tried  in  every  case  before 
a  surgical  operation  is  attempted,  and  in  children  it  will  prove 
satisfactory  in  the  majority  of  cases;  but  in  adults,  however, 
while  it  affords  much  relief,  a  permanent  cure  is  seldom  accom- 
plished. 

Non-surgical  treatment  is,  to  some  extent,  routine,  and  con- 
sists principally  in  improving  the  general  condition,  dieting, 
keeping  the  patient  in  the  recumbent  position  when  at  stool, 
regulating  the  bowel  to  overcome  straining  and  tenesmus, 
supporting  the  anus  during  the  intervals  of  defecation,  and  in 
the  local  application  of  cold,  astringent,  or  cauterizing  reme- 
dies. 

When  induced  by  whooping-cough,  phimosis ;  tumors  of 
the  rectum,  bladder,  uterus,  or  vagina;  diarrhea,  paralysis,  and 
in  fact,  any  ailment,  general  or  local,  tending  to  cause  relaxa- 
tion of  the  musculature  of  the  pelvic  outlet,  straining  or  drag- 
ging down  of  the  rectum,  these  conditions  must  be  corrected 
before  local  treatment  is  resorted  to.  Iron,  strychnine,  crea- 
sote,  codliver-oil,  malt,  and  other  remedies  of  this  class  render 


PROLAPSE  391 

g-ood  service  in  the  upbuilding  of  those  patients  whose  general 
condition  needs  to  be  improved  before  an  operation. 

Reduction  of  the  Protrusion.— When  the  protruded  mass 
does  not  return  spontaneously  or  has  not  been  replaced  by  the 
mother  or  attendant  before  the  physician  arrives,  the  first  duty 
of  the  latter  is  to  restore  the  bowel  to  its  normal  position  if 
possible. 

Anesthesia  is  required  only  in  exceptional  cases,  where  the 
bowel  is  edematous,  congested,  or  strangulated,  and  in  chil- 
dren who  are  extremely  nervous. 

When  it  is  desirable  to  reduce  the  prolapse,  the  patient, 
if  an  adult,  should  be  placed  in  the  knee-chest  posture,  or,  if  a 
child,  face  downward  across  the  knees.  Cleanse  the  bowel  and 
place  upon  it  a  piece  of  soft  hnen  or  silk,  well  oiled;  grasp  it 
in  the  hollow  of  the  hand,  making  general  and  even  pressure 
over  the  mass  until  the  feces,  or  the  serum  contained  in  the 
rectal  coats,  has  been  squeezed  out.  Then,  beginning  at  the 
distal  end,  gradually  work  the  protrusion  upward  through  the 
anus  by  taxis,  until  it  rests  well  above  the  sphincter. 

In  cases  where  it  is  doubtful  whether  reduction  can  be 
accomplished,  all  preparations  necessary  for  a  radical  opera- 
tion should  be  made  before  reduction  is  attempted. 

To  prevent  an  immediate  repetition  of  the  prolapse,  the 
buttocks  should  be  brought  together  over  it  and  fixed  with 
adhesive  strips;  or  a  cone-shaped  compress  should  be  placed 
over  the  anus  and  held  in  place  by  a  well-adjusted  T-bandage. 
The  patient  should  then  remain  in  bed.  The  dressing  should 
be  removed  only  when  there  is  an  action  of  the  bowels  and 
must  thereafter  immediately  be  replaced. 

During  treatment  for  procidentia  patients  should  defecate 
while  in  the  recumbent  posture,  in  order  to  eliminate  the  force 
which  is  exerted  upon  the  parts  by  the  abdominal  muscles  when 
the  act  of  defecation  is  performed  in  the  squatting  or  sitting 
position. 

The  daily  insertion  of  ice  and  the  injection  of  cold  water 
or  astringent  solutions  of  iron,  tannin,  iodine,  alum,  zinc,  silver, 
krameria,  and  infusions  of  oak-bark  or  kindred  drugs  are  the 
remedies  from  which  the  best  results  are  to  be  expected.  The 
strength  of  the  solutions  used  should  vary  according  to  the  ex- 
tent of  the  prolapse,  the  condition  of  the  mucous  membrane, 
and  the  patient's  ability  to  endure  them.     It  is  always  best  to 


393  DISEASES  OF  THE  RECTUM  AND  ANUS 

dilute  them  when  they  produce  nausea  or  colicky  pains  in  the 
abdomen. 

When  these  remedies  have  been  given  a  fair  trial  and 
fail,  Allingham  recommends  the  application  of  nitric  acid. 
Mathews,  on  the  other  hand,  deprecates  its  use  becaiise  of  the 
uncertain  amount  of  sloughing-  which  follows. 

The  author  has  successfully  applied  nitric  acid  for  the  relief 
of  prolapse  in  children.  The  surrounding  parts  are  first  pro- 
tected by  vaselin,  and  linear  cauterization  made  with  the  acid, 
applied  by  means  of  a  glass  rod.  The  length  of  the  cauterized 
lines  and  distance  apart  will  depend  upon  the  extent  of  the 
protrusion.  The  cauterization  being  completed,  a  piece  of 
gauze  or  cotton  should  be  inserted  into  the  rectum  to  keep  the 
rectal  walls  separated  and  to  absorb  any  excess  of  acid. 

The  treatment  of  procidentia  by  hypodermic  injection  of 


Fig.  127. — Prolapsus-Ani  Truss. 

various  remedies  into  the  coats  of  the  bowel  and  into  the  peri- 
rectal tissues  has  been  tried  with  varying  success.  The  ob- 
jects in  view  in  this  method  are  to  increase  tonicity,  set  up 
inflammatory  adhesion  between  the  coats,  and  to  produce 
shrinking  of  the  bowel  such  as  follows  the  injection  of  hemor- 
rhoids. Carbolic  acid,  ergotine,  and  nux  vomica  are  the  drugs 
ordinarily  used  for  this  purpose. 

My  colleague.  Dr.  Leonard  Weber,  of  New  York,  has 
several  times  observed  marked  improvement  following  the  in- 
jection of  strychnine.  He  maintains  that  the  good  results  are 
not  due  to  its  inflammatory  or  astringent  qualities,  but  to  the 
tonic  effect  upon  the  musculature  of  this  region.  The  injec- 
tion treatment  of  procidentia  is  undesirable,  for  the  reason  that 
it  is  frequently  followed  by  severe  pain,  abscess,  and  fistula, 
and  furthermore  because  it  rarely  produces  a  permanent  cure. 

Pessaries  and  trusses  of  various  sizes  and  shapes,  supported 


PROLAPSE  393 

by  a  suspensory  bandage  (Figs.  12Y  and  128),  have  been  de- 
vised to  retain  the  bowel  in  its  proper  position.  Such  appH- 
ances  are  uncomfortable,  and  are  soon  discarded,  because  they 
do  not  accomplish  what  is  expected  of  them. 

Dr.  Seneca  D.  Powell,  of  the  New  York  Post-graduate 
Medical  School  and  Hospital,  has  had  good  success  in  treating 
prolapse  in  children  by  holding  the  buttocks  together  with  adhesive 
strips,  which  are  kept  on  until  after  defecation.  After  stool  the 
parts  are  cleansed  and  the  straps  readjusted.  This  form  of 
dressing  elevates  and  supports  the  sphincter  and  prevents 
lateral  traction  during  defecation  in  the  squatting  position, 
eventually  restoring  tonicity  to  the  sphincter  and  involved 
muscles. 

SURGICAL  TREATMENT 

It  is  gratifying  to  know  that,  when  all  non-operative  meas- 
ures have  failed,  surgical  procedures  can  be  resorted  to  with  the 
assurance  that  they  will  prove  effective  in  the  majority  of  cases. 


Fig.  128.— Rectal  Plug. 

In  cases  of  acute  obstruction  due  to  invagination  of  the 
colon  or  sigmoid,  which  palliative  measures  have  failed  to  re- 
lieve, the  abdomen  should  be  opened  immediately,  the  invag- 
ination reduced,  and  a  portion  of  the  gut  resected  if  necessary. 
Ashhurst  (Jr.),  Sands,  Bryant,  Hutchinson,  and  Manse  were 
the  first  surgeons  to  resort  to  laparotomy  for  the  relief  of  this 
condition. 

The  operations  devised  for  the  relief  of  procidentia  recti 
are  numerous,  but  only  those  will  be  described  which  have  been 
tried  with  success. 

Any  operation  to  be  successful  must  accomplish  the  fol- 
lowing objects : — 

1.  Produce  sufficient  inflammation  to  cause  an  adhesion  be- 
tween the  rectal  coats  so  that  one  will  not  slip  over  the  other. 

2.  Remove  redundant  tissue  in  order  that  the  caliber  of  the 
bowel  may  be  narrozved. 


394  DISEASES  OF  THE  RECTUM  AND  ANUS 

3.  Reduce  the  size  of  the  anal  aperture. 

Minor  Operations. — In  partial  prolapse  folds  of  mucous 
membrane  may  be  clamped,  cut  away,  and  cauterized  (Bean's 
operation),  or  the  edges  may  be  sutured  together  with  catgut 
before  the  clamp  is  removed.  The  author  has  tried  both  meth- 
ods with  success  in  mild  cases.  He  has  also  succeeded  in  curing 
partial  procidentia  by  picking  up  several  small  areas  of  the  mu- 
cosa and  clamping  them  with  the  Gant  "valve"-clamps  (Plate 
IX),  or  by  removing  small  areas  or  elongated  sections  of  the 
membrane  by  ligation  or  excision  and  suture  under  local  anes- 
thesia. The  inflammation  and  cicatrization  following  were  suffi- 
cient to  bring  about  the  desired  result.  Urbane  has  succeeded 
in  curing  prolapse  by  placing  a  silver  wire  around  the  bowel  just 
beneath  the  mucous  membrane  and  above  the  external  sphincter. 
The  author  has  accomplished  the  same  by  means  of  hardened 
catgut  ligatures,  which  were  left  in  situ  for  several  days. 

Gant's  Wire  Operations.  —  Through  a  posterior  median  in- 
cision, extending  from  the  middle  of  the  sacrum  to  within  half 
an  inch  of  the  anus,  the  coccyx  is  excised  and  the  rectum  freed 
from  its  attachments.  A  fine  silver-wire  mattress,  half  an  inch 
in  width  (1.27  centimeters)  and  eighteen  inches  (45.7  centime- 
ters) in  length,  is  then  wrapped  in  spiral  fashion  around  the  free 
portion  of  the  bowel,  working  from  below  upward,  and  fastened 
in  place  by  a  number  of  fine  wires  bound  around  it  at  intervals 
of  half  an  inch  (1.27  centimeters).  Sufficient  pressure  is  used 
to  give  to  the  inner  surface  of  the  bowel  a  somewhat  corrugated 
appearance.  Longitudinal  wire  splints  have  also  been  used  suc- 
cessfully in  this  operation.  The  incision  is  then  closed  with 
catgut. 

The  wire  becopies  encysted  and  the  good  results  following 
this  operation  are  due  evidently  to  the  support  given  the  bowel 
and  to  the  adhesions  resulting  from  the  inflammation. 

OPERATIONS  FOR  THE  REDUCTION  OF  THE  CALIBER  OR  LENGTH 
OF  THE  RECTUM  AND  SHORTENING  OF  THE  SPHINCTER- 
MUSCLE 

Linear  Cauterization.  —  Taking  one  case  with  another,  the 
most  reliable  operation  is  linear  cauterization.  This  operation 
was  devised  by  an  American  surgeon,  the  late  Dr.  Van  Buren, 
of  New  York,  and  has  been  sanctioned  by  Cripps  and  many 
other  authorities  on  rectal  diseases. 

It   is   performed    as    follows :     After   the   bowel   has   been 


PROLAPSE 


395 


thoroughly  cleansed  and  the  patient  anesthetized,  place  him 
in  the  lithotomy  position  and  reduce  the  prolapse.  Introduce 
the  author's  operating  speculum  and  separate  the  rectal  walls. 
With  the  Paquelin  thermocautery  (flat  point)  make  a  number 
of  parallel  lines,  half  an  inch  (1.27  centimeters)  apart,  begin- 
ning three  inches  (7.5  centimeters)  above  and  terminating  at 
the  margin  of  the  anus.  The  lines  are  to  be  made  deeper  and 
nearer  together  if  the  severity  of  the  case  demands.  The  aver- 
age surgeon  does  not  succeed  in  producing  sufficient  cicatricial 
tissue  because  of  the  superficial  nature  of  his  cauterizations. 

The  author  has  performed  linear  cauterization  in  many 
cases  of  prolapse,  some  of  which  were  very  severe,  and  has 
found  it  eminently  satisfactory.     In  a  few  cases,  however,  he 


^■ic. 


Fig.  129.— Gant's  Operation  for  Proci- 
dentia Recti.  First  Step:  Bowel  Pushed 
Out  Through  Transverse  Sliin  Incision 
and  Incised  Longitudinally. 


Fig.  130.— Gant's  Operation  for  Proci- 
dentia Recti.  Second  Step:  Longitudi- 
nal Incision  Pushed  up,  Made  Trans- 
verse, and  Sutured. 


had  to  repeat  the  operation  two  or  three  times  before  a  cure 
was  complete. 

Dupuytren's  Operation. — This  operation  consists  in  remov- 
ing an  elliptic  fold  of  integument,  including  a  portion  of  the 
mucous  membrane,  at  three  equidistant  points  at  the  anal  out- 
let. This  operation  has  been  modified  by  Dieffenbach,  Mott, 
Roberts,  Lange,  and  Gant.  They  have  gone  a  step  farther  and 
removed  long  and  deep  sections  of  both  the  rectum  and  sphinc- 
ter-muscle, and  then,  by  closing  the  wound,  produced  a  nar- 
rowing of  both. 

Gant's  Posterior  Proctoplasty. — In  cases  of  moderate  pro- 
lapse the  author  has  on  three  occasions  accomplished  a  cure 
by  attacking  the  bowel  from  behind  and  shortening  it  several 
inches.     The  steps  of  this  operation  are  as  follows: — 


396  DISEASES  OF  THE  RECTUM  AND  ANUS 

With  the  patient  in  the  exaggerated  Sims  position,  under 
aseptic  conditions  an  incision,  one  and  a  half  inches  (3.8  centi- 
meters) in  length,  is  made  just  below  and  transverse  to  the 
coccyx  and  carried  down  to  the  rectum,  which  is  freed  from  its 
posterior  attachments.  The  sphincter  is  then  divulsed,  and, 
with  the  index  and  middle  fingers  passed  full  length  into  the 
rectum,  the  bowel  is  pushed  out  through  the  opening  and 
pulled  down  as  far  as  possible  (Fig.  129). 

A  longitudinal  incision,  from  two  to  four  inches  (5  to  10 
centimeters)  in  length,  is  now  made  through  the  rectal  coats^ 
(Fig.  129),  and  the  bowel  is  shortened  the  length  of  this  in- 
cision by  bringing  the  angles  of  the  cut  together,  thus  making 


Fig.  131. — Gant's  Operation  for  Procidentia  Recti.  Third  Step:  Showing 
the  Skin  Incision  Closed  with  Interrupted  Catgut  Sutures  After  the  Bowel 
has  been  Returned. 

its  direction  transverse  and  closing  it  with  the  Lembert  sutures 
of  fine  silk  or  catgut  (Fig.  130).  Before  inserting  the  stitches 
all  hemorrhage  must  be  arrested.  The  wound  is  then  dusted 
over  with  aristol,  and  the  gut  returned  through  the  external 
incision,  which  is  then  closed  with  catgut  (Fig.  131). 

The  rectum  should  now  be  irrigated  and  dried  and  the 
intrarectal  wound  protected  from  infection  by  non-absorbable 
wool,  dusted  over  with  iodoform. 

While  no  complications  occurred  in  the  three  cases  treated 
by  posterior  proctoplasty,  the  author  nevertheless  realizes  the 
danger  of  infection,  abscess,  and  fistula  from  this  procedure 
unless  strict  asepsis  be  maintained. 

'  In  one  sucressful  case  the  incision  was  only  carried  through  the  muscular  coats. 


PROLAPSE  397 

Lange's  Operation.  —  With  the  patient  in  the  knee-chest 
position,  a  posterior  median  incision  is  made  from  the  sacrum 
to  the  anus  and  the  coccyx  removed.  The  bowel  is  scarified 
and  narrowed  by  buried  sutures  so  placed  that  when  tied  they 
produce  a  fold  or  tuck  projecting  into  the  lumen  of  the  bowel. 
The  cut  edges  of  the  levator  ani  and  sphincter  externus  are 
then  united,  a  piece  of  iodoform  gauze  is  inserted  into  the 
cavity  of  the  wound  and  the  external  wound  closed  around  the 
drain.  Iodoform  catgut  sutures  are  used  throughout  the  oper- 
ation. 

Roberts's  Operation. — Through  a  posterior  median  incision 
just  below  the  coccyx  the  attachments  of  the  rectum  are  broken 
up  with  the  finger.  The  knife  is  then  passed  into  the  bowel 
and  two  deep  incisions  are  made,  beginning  at  a  point  three 
inches  (7!62  centimeters)  above  the  sphincter  and  passing 
obliquely  downward  on  either  side  of  the  median  Hne  through 
the  anus  to  join  the  first  incision.  The  triangular  shaped  piece 
of  tissue — composed  of  the  mucous  membrane,  muscular  coats 
of  the  bowel,  an  inch  (2.5  centimeters)  of  the  sphincter-muscle, 
and  the  attached  skin — is  carefully  removed.  Bleeding  vessels 
must  now  be  ligated  and  the  rectal  portion  of  the  wound  closed 
with  interrupted  sutures  of  chromicized  catgut,  the  lowermost 
one  being  placed  just  above  the  anal  margin.  After  a  drain 
has  been  placed  in  the  wound  leading  to  the  coccyx,  it  is  closed 
with  deep  silk  or  shotted-wire  sutures. 

FIXATION  OF  THE  BOWEL  TO  THE  SACRO=COCCYGEAL 

CURVE 

Verneuil's  Operation. — In  this  operation  a  triangular  flap 
of  skin  and  subcutaneous  tissue  is  made  with  a  base  two  inches 
(5  centimeters)  long  just  below  and  at  right  angles  to  the  coc- 
cyx and  the  apex  near  the  anus.  The  flap  is  turned  downward 
and  the  rectum  freed  from  its  posterior  attachments.  Four 
sutures  are  inserted  transversely  through  the  musculature  of 
the  rectum  and  brought  out  half  an  inch  (1.27  centimeters)  on 
either  side  of  the  median  line.  This  is  accomphshed  by  means 
of  a  needle  having  an  eye  near  the  point,  which  is  pushed 
through  the  skin  and  subcutaneous  tissue,  threaded,  and  with- 
drawn, carrying  the  suture.  The  highest  suture  should  be  on 
a  level  with  the  sacro-coccygeal  articulation  and  the  lowest  at 
the  point  of  the.  coccyx.    The  bowel  is  drawn  up  into  the  curve 


398  DISEASES  OF  THE  RECTUM  AND  ANUS 

and  secured  by  tying  together  the  first  and  second  and  the  third 
and  fourth  sutures  over  pads  of  iodoform  gauze.  The  flap  is 
then  replaced  and  sutured. 

Fowler's  Operation.  —  Verneuil's  method  was  modified  in 
1897^  by  Dr.  George  Ryerson  Fowler,  of  Brooklyn.  He  de- 
scribes the  technic  as  follows :  "In  a  case  successfully  operated 
upon  by  myself,  I  modified  this  operation  by  making  the  in- 
cision semicircular  in  shape  and  half-way  between  the  anal 
margin  and  the  point  of  the  coccyx.  The  dissection  is  carried 
well  up  between  the  rectum  and  sacrum.  With  two  fingers  in 
the  rectum  the  posterior  wall  of  the  latter  is  forced  through  the 
external  wound,  and  four  sutures  of  heavy,  chromicized  catgut 
passed  transversely  through  the  posterior  rectal  wall,  including 
all  its  tissues,  to  the  mucous  membrane.  A  short  incision  is 
then  made  down  to  the  bone  at  the  junction  of  the  sacrum  and 
coccyx,  and  the  sutures  brought  out  upon  corresponding  sides 
of  the  latter  and  tied  across  the  bone,  strong  traction  being 
made  to  bring  the  rectum  in  position.  This  skin-wound  is  now 
closed.  The  incision  between  the  point  of  the  coccyx  and  the 
anus  is  now  closed,  except  at  the  central  portion,  in  which  an 
iodoform-gauze  drain  is  inserted.  A  further  improvement 
would  be  to  pass  the  sutures  through  the  posterior  wall  of  the 
rectum,  so  as  to  produce  an  infolding  effect,  as  in  Lange's 
operation,  by  drawing  the  lateral  portions  of  the  rectal  wall  to 
the  median  line  and  there  securing  them  by  tying.  The  long 
ends  of  the  same  sutures  may  now  be  used  for  suspending  and 
fixing  the  rectum."  In  the  succeeding  cases  operated  upon  by 
this  method  he  also  produced  a  narrowing  at  the  anus  by 
throwing  a  purse-string  suture  of  silk  or  kangaroo-tendon 
about  the  lower  end  of  the  bowel  beneath  the  mucosa,  as  had 
been  advised  long  ago  by  Piatt,  of  Boston.  Dr.  Fowler  in- 
formed the  writer  that  the  results  following  these  operations 
were  entirely  satisfactory. 

In  the  June,  1901,  issue  of  the  International  Journal  of  Sur- 
gery, Dr.  J.  P.  Tuttle  describes  an  operation  for  the  relief  of 
procidentia  recti  which  is  similar  in  many  respects  to  that  of 
Fowler,  and  reports  nine  cases  treated  with  success. 

Ventral  Fixation  (Proctopexy,  Rectopexy,  Sig-moidopexy,  Colo- 
pexy). — Ventral  fixation  consists  in  lifting  up  of  the  bowel  and 
attaching  it  to  the  inner  abdominal  parietes. 

1  Medical  News,  February  27,  1897. 


PROLAPSE  399 

Mr.  Herbert  W.  Allingham,  in  1888,  was  the  first  to  sug- 
gest an  elongated  mesentery  as  the  cause  of  procidentia  recti 
and  that  the  condition  could  be  reheved  by  this  procedure. 
McLeod,  in  1890;  Berg,  in  1893;  Cady,  of  Calcutta,  in  1894; 
and  Hearn  have  also  done  much  to  emphasize  the  value  of 
ventral  fixation  in  aggravated  cases  of  procidentia  recti. 

There  are  two  ways  of  performing  this  operation :  (a)  by 
preliminary  laparotomy  and  (b)  by  introducing  the  hand  into 
the  rectum  and  pushing  the  bowel  upward. 

Preliminary  Laparotomy  (Celiotomy).  —  This  operation  is 
simple,  effective,  not  dangerous,  and  can  be  performed  in  a 
short  time.  The  author  has  successfully  performed  this  opera- 
tion either  alone  or  in  conjunction  with  other  operations  for  the 
relief  of  persistent  cases  of  prolapse  complicated  by  invagina- 
tion. The  steps  of  the  operation  are  as  follows:  The  abdom- 
inal cavity  is  entered  through  a  free  incision  below  the  um- 
bilicus and  to  the  outer  side  of  the  left  rectus  muscle.  The 
colon,  sigmoid,  or  rectum  is  located  as  the  case  demands,  and 
drawn  upward  until  taut.  The  gut  is  then  scarified  and  fast- 
ened to  the  inner  abdominal  parietes  by  three  or  four  small 
chromicized  catgut  or  silk  sutures  placed  half  an  inch  (1.27  cen- 
timeters) apart,  and  including  all  the  tunics  of  the  bowel  except 
the  mucosa. 

The  bowel  may  be  anchored  by  the  sutures  used  to  close 
the  wound  or  by  independent  stitches  passed  through  the  ab- 
domen to  the  outer  side  of  the  incision. 

Mathews,  of  Louisville,  recently  reported  the  cure  of  a  most 
aggravated  case  of  procid.entia  by  anchoring  the  colon  to  the 
abdominal  wall  with  chromicized  interrupted  catgut  sutures. 
The  prolapsed  tumor  contained  all  the  coats  of  the  rectum, 
peritoneum,  and  bladder,  and  Dr.  Mathews  states  that  it  was 
as  large  as  a  No.  7  Derby  hat. 

McLeod's  Operation.  —  Introduce  the  left  hand  into  the 
bowel  until  the  fingers  are  prominent  above  Poupart's  liga- 
ment. Then  push  an  acupressure-needle  through  the  abdo- 
men at  this  point  into  the  gut,  and  across  it  and  outward  until 
it  emerges  three  inches  (7.5  centimeters)  from  the  point  of 
entrance,  using  the  fingers  as  a  guide.  A  second  needle  is 
similarly  introduced  three  inches  (7.5  centimeters)  above  the 
first.  The  abdomen  is  then  opened  between  the  needles,  and 
the  gut  sutured  to  the  abdominal  wall  by  silk  sutures,  which 


400  DISEASES  OF  THE  RECTUM  AND  ANUS 

include  the  serous  and  muscular  coats.  The  wound  is  closed 
and  the  needles  allowed  to  remain  in  place  twenty-four  hours. 

Gant's  Combined  Operation In  many  cases  of  long  stand- 
ing there  is  not  only  a  prolapse  of  the  rectal  coats,  but  an 
invagination  of  the  sigmoid  as  well,  and  no  operation  upon 
the  former,  however  radical,  will  be  successful.  In  order  to 
relieve  this  most  annoying  condition  the  author  has  many  times 
performed  with  entire  satisfaction  a  combined  operation  em- 
bracing the  principal  features  as  advocated  by  Van  Buren, 
Roberts,  and  Herbert  Allingham  for  the  relief  of  procidentia. 

Technic. — 1.  The  abdomen  is  opened,  and  the  sigmoid 
located  and  pulled  up  out  of  the  pelvis  until  it  is  taut,  when 
it  is  scarified  and  fixed  to  the  inner  abdominal  wall  by  three  or 
more  chromicized  catgut  or  silk  sutures,  after  which  the  abdom- 
inal wound  is  closed. 

2.  Through  a  large  rectal  speculum  or  proctoscope  a 
linear  cauterization  is  made  of  the  middle  and  upper  portion  of 
the  rectum  as  far  up  as  it  can  be  reached. 

3.  A  V-shaped  segment  of  the  rectal  wall  and  sphincter- 
muscle  is  then  removed  by  making  two  deep  incisions,  begin- 
ning at  a  point  three  inches  (7.5  centimeters)  above  the  anus 
and  passing  downward  and  backward  through  the  anus  to  the 
tip  of  the  coccyx,  including  one  inch  (2.5  centimeters)  of  the 
sphincter,  skin,  and  subcutaneous  structures.  The  edges  of  the 
wound  are  then  united  with  silk  or  catgut  and  protected  with 
a  dry  dressing. 

It  takes  about  t\w^nty  minutes  to  perform  the  combined 
operation,  and  the  patient  should  be  required  to  remain  in  bed 
for  about  three  weeks.  The  first  step  relieves  the  invagination 
of  the  sigmoid,  the  second  causes  adhesion  between  the  rectal 
coats,  and  the  third  narrows  the  bowel-caliber  and  diminishes 
the  size  of  the  anus. 

Thus  far  the  author  has  not  met  with  any  unpleasant  com- 
plications or  sequels  following  this  combined  operation,  and 
heartily  recommends  it. 


AMPUTATION,    EXCISION,   AND   RESECTION 

Amputation  of  the  protruding  mass  of  bowel  for  the  relief 
of  procidentia  recti  has  been  practiced  by  both  ancient  and 
modern  surgeons.  The  removal  of  the  bowel  may  be  accom- 
plished by  the  aid  of  the  knife,  clamp  and  cautery,  elastic  liga- 


PEOLAPSE  401 

ture,  or  ecraseur,  the  knife  being  preferable  in  most  cases 
where  removal  of  a  part  of  the  entire  circumference  of  the 
bowel  is  desirable. 

Such  men  as  Allingham,  Cripps,  and  other  authorities  on 
rectal  diseases  do  not  look  upon  excision  with  much  favor. 

The  principal  dangers  of  this  operation  are  hemorrhage, 
stricture,  infection  of  the  peritoneal  cavity,  and  injury  to  the 
small  intestines  when  the  procidentia  is  complicated  by  hernia. 
Moreover  it  is  a  difficult  matter  to  determine  just  how  much 
bowel  should  be  removed.  In  fact,  excision  is  not  a  suitable 
operation  in  the  majority  of  cases,  because  these  sufferers  can 
be  cured  by  less  difficult  and  dangerous  operations.  This  pro- 
cedure is  of  great  value,  however,  in  aggravated  cases  and 
should  be  attempted  when  less  radical  measures  have  failed. 
A  very  reliable  method  of  resecting  the  required  amount  of 
gut  is  as  follows:  Make  an  incision  around  and  through  the 
bowel  immediately  above  the  sphincter  (to  avoid  incontinence), 
and,  with  the  finger  or  blunt  scissors,  carefully  separate  it  from 
the  surrounding  structures  as  high  up  as  necessary.  Grasp  it 
with  the  fingers  or  strong  forceps,  pull  down  until  taut,  and 
amputate  the  now  protruding  portion.  Unite  the  stump  to  the 
lower  segment  with  interrupted  plain  or  chromicized  catgut  or 
silk  sutures.  Introduce  a  few  strips  of  antiseptic  gauze  into  the 
rectum,  and  place  the  patient  in  bed.  Wire  or  silk-worm-gut 
sutures,  when  used  for  this  purpose,  frequently  cut  their  way 
out,  thereby  causing  unnecessary  pain. 

Where  the  prolapse  is  more  extensive  and  comphcated  by 
invagination  of  the  upper  rectum  or  sigmoid,  and  the  bowel  is 
much  thickened,  a  more  radical  operation  is  necessary,  because 
the  peritoneal  attachment  prevents  a  sufficient  length  of  gut: 
being  pulled  down  and  resected.  In  such  cases  it  becomes  nec- 
essary to  make  a  posterior  median  incision  and  remove  the 
coccyx  and  sometimes  a  part  of  the  sacrum.  Through  this 
opening  the  peritoneal  attachment  of  the  rectum  can  be  severed 
and  the  required  length  of  bowel  pulled  down,  resected,  and 
sutured  as  previously  described.  In  exaggerated  cases  of  long 
duration,  where  the  rectum  is  extensively  ulcerated  and  bur- 
rowing fistulas  exist  between  the  rectal  coats,  the  more  radical 
operation  is  especially  indicated.  Where  incontinence  is  com- 
plete prior  to  operation,  the  sphincter-muscle  may  be  ignored. 


402  DISEASES  OF  THE  RECTUM  AND  ANUS 

Mikulicz's  Operation. — The  protruding  mass  is  grasped  be- 
tween the  thumb  and  index  finger  of  the  left  hand  and  the 
outer  cylinder  divided  by  making  a  number  of  short  incisions, 
each  time  stitching  the  outer  to  the  inner  cyhnder  to  prevent 
retraction.  Should  a  hernia  exist,  extreme  care  must  be  taken 
to  avoid  injury  to  the  intestine.  When  the  incisions  and  stitch- 
ing have  been  carried  entirely  around  the  outer  cylinder,  the 
inner  is  grasped  with  forceps  and  severed.  The  edges  of  the 
mucous  membrane  are  then  approximated  by  a  continuous 
catgut  suture  and  the  stump  cleansed  and  replaced  above  the 
sphincter. 

Treves's  Operation  consists  in  severing  the  membrane  en- 
tirely around  the  bowel  near  the  base  of  the  protrusion,  thus 
exposing  the  prolapsed  gut  beneath.  By  blunt  dissections  it  is 
freed  from  the  latter  and  everted.  The  pelvis  is  then  raised, 
to  cause  retraction  of  the  small  intestine;  the  remaining  part 
of  the  protruding  bowel  is  cut  away  near  the  anus;  the  peri- 
toneum is  retracted,  bleeding  arrested,  and  the  rectal  coats  are 
prevented  from  slipping  upward  by  clamp  forceps.  The  peri- 
toneum is  next  closed  with  chromicized  gut,  and  the  ends  of 
the  severed  bowel  united  with  silk-worm-gut  sutures  near  the 
anal  margin,  including  all  the  rectal  coats. 

Kleberg's  Bloodless  Operation.  —  The  prolapsed  gut  is 
grasped  all  around  by  an  assistant,  and  held  until  a  strong 
gum-elastic  ligature  is  placed  around  it  less  than  an  inch  (2.5 
centimeters)  from  the  anus.  The  peritoneal  cavity  and  loops 
of  the  small  intestine  are  exposed  by  a  longitudinal  incision 
two  inches  (5  centimeters)  long  through  the  protruding  mass. 
By  adjusting  the  ligature  bleeding  is  prevented,  while  the  in- 
testinal loops  are  being  returned  through  the  ligature.  A 
double  elastic  ligature  is  passed  through  the  protruding  bowel, 
and  it  is  ligated  in  two  sections,  the  knots  being  secured  with 
silk  or  shot.  The  primary  ligature  is  removed  and  the  gut  cut 
oiT  one  inch  (2.5  centimeters)  in  front  of  the  permanent  liga- 
tures, and  zinc  chloride  solution  applied  to  the  bowel  above 
them.  The  originator  has  performed  this  operation  twice  ;  the 
first  patient  was  cured  and  the  second  died.  Both  were  ag- 
gravated cases. 

Fowler's  Operation.  —  Dr.  George  Ryerson  Fowler,  of 
Brooklyn,  prefers  the  combined  lithotomy-Trendelenburg  posi- 
tion and  spinal  cocainization  in  excision.     The  former  prevents 


PEOLAPSE 


403 


descent  of  the  small  intestine  and  the  latter  permits  the  volun- 
tary extrusion  or  retraction  of  the  bowel  by  the  patient  during 
the  operation.  In  removing  the  gut  the  mucous  membrane  is 
first  incised  one-half  inch  (1.27  centimeters)  below  the  anus  and 
dissected  back.  The  cut  is  then  deepened,  and  the  outer  cylin- 
der is  sutured  to  the  inner.  In  succeeding  steps  the  sutures  are 
adjusted  before  the  cut  is  made,  thus  protecting  the  peritoneal 
cavity  until  the  entire  circumference  of  the  bowel  has  been 
severed.  In  other  respects  his  method  does  not  differ  mate- 
rially from  the  operations  previously  described. 

Mathews,    of   Louisville,    has    successfully    relieved    proci- 
dentia by  making  a  circular  incision  around  the  protruding 


Fig.   132.— Submucous   Operation  for  Procidentia   Recti. 


mass  just  without  the  anus.  A  second  incision  is  then  made 
around  the  bowel  near  the  distal  end  of  the  tumor.  The  cuts 
extend  through  the  mucous  membrane  only,  and  that  portion 
of  the  mucosa  lying  between  the  incisions  is  carefully  dissected 
off  and  the  divided  ends  of  the  mucous  membrane  are  then 
united  with  catgut  sutures  and  the  gut  thus  shortened. 

Rickets's  Operation  (Submucous  Ligation). — Dr.  Merrill  Rick- 
ets, of  Cincinnati,  speaks  highly  of  submucous  ligation  in  the 
treatment  of  rectal  prolapse.  The  paraphernalia  necessary  for 
this  operation  are  a  specially-constructed  needle  describing 
somewhat  more  than  a  semicircle  (Fig.  132),  and  a  few  kanga- 


404 


DISEASES  OF  THE  RECTUM  AND  ANUS 


roo-tendons.  The  needle  carrying  the  tendon  is  made  to  pene- 
trate the  mucous  membrane  just  within  the  anus  and  describe 
a  half-circle  in  the  submucous  tissue  (Fig.  132),  when  it  is 
brought  out  and  reintroduced  at  the  same  point,  continuing  the 
circle  until  it  emerges  at  the  point  of  entrance.  The  ligature  is 
then  tied,  including  all  the  structures  within  its  grasp.  From 
two  to  six  such  areas  are  ligated  according  to  the  severity  of 
the  case,  and,  where  all  the  rectal  coats  are  prolapsed,  the 
sutures  are  placed  deep  in  the  muscular  tissue. 

The  originator  of  this  operation  maintains  that  the  irrita- 
tion excited  by  the  ligature  is  sufficient  in  degree  and  duration 
to  produce  permanent  adhesions  and  effect  a  cure. 

ILLirSTIlATIVE  CASES 
Case  XXIV.     Prolapse   Due   to   Summer  Diarrhea    (Cauterization). — A 

little  girl,  2  years  old,  was  brought  to  the  dispensary  to  be  treated  for  piles. 


Fig.  133. — Le  Roy  Indestructible  Cautery, 


Her  mother  said  that  the  child  had  been  suffering  from  summer  complaint 
for  three  weeks;  the  stools  were  frequent  and  caused  much  pain  and  straining; 
while  on  the  chamber  half  an  hour  before,  the  piles  came  down.  I  placed  the 
child  across  my  knees,  flexed  the  limbs,  and  a  tumor  the  size  of  a  hen's  egg 
(Fig.  122)  presented  itself  just  outside  the  anus.  It  was  soft,  smooth,  and 
globular  in  shape,  with  a  slit  in  the  center.  The  case  proved  to  be  a  typic 
one  of  prolapse  of  the  mucous  membrane.  The  sphincter  was  relaxed,  and 
every  time  the  tumor  was  returned  within  the  bowel  it  would  immediately 
reappear. 

Treatment. — Chloroform  was  administered  and  the  tumor  reduced;  then 
the  cautery-point  was  introduced  up  the  bowel  for  two  inches  (5  centi- 
meters) and  then  brought  down  and  outward.  This  was  repeated  a  number 
of  times,  until  there  were  a  number  of  parallel  lines  about  half  an  inch 
(1.27  centimeters)  apart.  A  piece  of  gauze  smeared  over  with  vaselin  was 
placed  in  the  rectum  to  keep  the  walls  separated.  The  buttocks  were  then 
strapped  tightly  together  with  adhesive  plaster  to  support  the  anus.  An 
opiate  was  given  to  tie  up  the  bowels  and  the  child  sent  home.     Two  days 


PROLAPSE 


405 


afterward  the  straps  were  removed  and  a  good  fecal  action  followed;  then 
the  straps  were  replaced.  Three  months  later  I  saw  her  again.  She  had  been 
perfectly  well  ever  since  the  operation. 

Case  XXV.  Extensive  Prolapse  of  All  the  Rectal  Coats. — Dr.  P.  came 
to  me  to  have  an  operation  performed  for  prolapse  of  the  rectum,  and  gave 
the  following  history:  Aged  38;  country  practitioner;  general  health  good 
except  that  he  suffered  more  or  less  from  constipation  and  headache.  He 
seldom  had  an  action  more  than  twice  a  week,  and  then  it  was  attended 
with  violent  straining  and  protrusion  of  the  bowel.  Sometimes  only  the 
mucous  membrane  was  everted;    at  other  times  all  of  the  rectal  coats  came 


Fig.  134. — Dwarfed  Child  Suffering  from  Extensive  Prolapse  of  the  Rectum. 


down  for  several  inches,  and,  when  not  promptly  returned,  became  swollen 
and  very  difficult  to  reduce. 

Treatment.- — He  was  anesthetized  and  the  cautery  (Fig.  133)  applied 
deeply  into  the  mucous  membrane  after  Van  Buren's  method.  It  was  then 
pressed  deep  down  into  the  external  sphincter  in  three  equally  distant  places 
to  insure  contraction.  The  bowels  were  tied  up  for  a  week  and  the  diet 
restricted  to  milk  and  soft-boiled  eggs.  On  the  seventh  day,  after  taking  a 
Seidlitz  powder,  he  had  a  copious  movement;  the  bed-pan  was  used  and  he 
remained  in  a  recumbent  position.  The  rectum  was  irrigated,  and  balsam  of 
Peru  applied  to  the  mucous  membrane.     Ten  days  from  the  time  he  entered 


406 


DISEASES  OF  THE  RECTUM  AND  ANUS 


the  hospital  he  returned  home.  He  called  a  few  months  later  and  said  that 
the  rectum  had  not  troubled  him  in  the  least  since  the  operation. 

Case  XXVI.  Extensive  Prolapse  (Excision). — A  lady  applied  to  me  for 
treatment  for  extensive  prolapse.  She  had  been  operated  on  twice  before 
by  Van  Buren's  method. 

Operation. — It  was  decided  to  excise  the  redundant  tissue,  which  was 
done  after  the  following  manner:  An  incision  was  made  around  the  anus  at 
the  muco-cutaneous  junction,  and  the  mucous  membrane  dissected  up  for  two 
incnes  (5  centimeters).  The  dissected  mucous  membrane  was  then  pulled 
down,  cut  off,  and  the  cut  edge  attached  to  the  skin  by  catgut  sutures.    Anti- 


Fig.  135. — Appearance  of  Dwarfed  Child  Eighteen  Months  After  Cure  of  Prolapse, 
Showing  the  Effect  of  Operation  and  Thyroid  Treatment. 


septic  dressings  were  applied,  and  union  was  complete  within  ten  days.  She 
was  then  discharged  with  instructions  to  keep  her  bowels  open  and  to  report 
if  the  bowel  came  down  again.  One  year  afterward  I  met  her  and  she  in- 
formed me  that  she  had  had  no  further  trouble. 

Case  XXVII.  Dwarfed  Child  Suffering  from  Prolapse. — Some  years 
ago  I  was  called  to  see  a  dwarfed  child  who  had  suffered  from  the  time  he 
was  6  weeks  old  with  obstinate  constipation  and  extensive  prolapse  of  the 
rectal  coats,  which  the  father  thought  were  the  cause  of  the  arrested  develop- 
ment. He  was  14  years  old,  weighed  38  pounds,  and  measured  thirty-two 
inches  (81.28  centimeters)  in  height  (Fig.  134).  During  the  eleven  years 
previous  he  had  not  gained  one  ounce  in  weight  nor  one  inch  (2.54  centi- 
meters) in  height.    Another  interesting  feature  in  this  case  was  that  he  had 


PROLAPSE  407 

an  angioma  between  the  thumb  and  forefinger  of  the  right  hand.  This  the 
family  physician  lanced  for  an  abscess  and  came  near  losing  the  patient  from 
hemorrhage.  This  lad  was  treated  by  the  cautery  method  and  the  prolapse 
was  cured.    I  cite  this  case  merely  because  it  is  unique. 

Six  montns  after  the  above  notes  were  made  I  saw  the  child  again, 
and  decided  to  try  desiccated  thyroid.  The  improvement  in  his  general  ap- 
pearance following  its  use  was  marked.  His  countenance  changed  entirely, 
his  speech  improved,  he  grew  rapidly,  and  showed  considerable  mental  develop- 
ment. I  have,  through  the  father's  kindness,  a  late  picture  of  the  boy  (Fig. 
135),  which  I  scarcely  recognized  at  first  sight.  The  dose  of  desiccated  thyroid 
gland  given  in  this  case  was  2  grains  every  four  to  six  hours. 


LITERATURE  ON  PROCIDENTIA  RECTI 


Allingham:    "Procidentia  Recti,"  "Diseases  of  the  Rectum  and  Anus,"  p.  187, 

1888. 
Bryant:    "Physiologic  Rest  in  Prolapse,"  Mathews's  Med.  Quart.,  vol.  i,  p.  513, 

1894. 
Fowler:    Med.  Neios,  Dec.  8,  1900. 
Hajech:    "Di  un  mezzo  di  cura  del  prolasso  del  Retto  nei  Bambini,"  Gazz.  Deg. 

Osp.,  Milano,  vol.  xLx,  pp.  1604-1606,  1898. 
Jeannel:    "Du  prolapsus  du  Rectum,"  Clin,  de  la  Fac.  de  Med.  de  Toulouse, 

vol.  ii,  pp.  101-121,  1896. 
Kleberg:    Arch.  f.  klin.  Chir.,  Bd.  xxiv,  p.  841,  1879. 
Lange:    Annals  of  Surgery,  vol.  v,  p.  497,  1887. 

Manley:    "Proctoptoma  Hominis,"  Mathews's  Med.  Quart.,  vol.  iv,  p.  5,  1897. 
Mathews:    Joi(r.  Amer.  Med.  Assoc,  Mar.  30,  1901. 

Maylard:    "Prolapse,"  "Surgery  of  the  Alimentary  Canal,"  pp.  637-653,  1896. 
McLeod:    Lancet,  London,  July  19,  1890. 
Mikhailoflf:      "Prolapse    with    Subsequent    Purulent    Peritonitis,"    Khirurgia, 

Mosk.,  vol.  i,  pp.  315-317,  1897. 
Mikulicz  (Bogdanik) :    Arch.  f.  Uin.  Chir.,  vol.  xlviii,  p.  847,  1894. 
Paquet:    "Traitement  du  prolapsus,"  Ann.  de  Chir.  et  d'Orthop.,  Paris,  vol.  xi, 

p.  206,  1898. 
Fauchet:    "Traitement  du  prolapsus,"  Gaz.  med.  de  Picardie,  Amiens,  vol.  xvi, 

p.  199,  1898. 
Rehn:    "Ueber  die  haiifigsten  Formen,"  etc.,  Aertzl.  Prax.  Wiirzb.,  vol.  xi,  p.  3, 

1898. 
Rickets:    "Submucous  Ligature  for  Prolapse,"  Med.  Rev.  of  Rev.,  vol.  vi,  p. 

512,  1900. 
Roberts:    "Prolapse  of  the  Rectum,"  "Modern  Surgery,"  p.  636,  1890. 
Schaeffer:      "Kongenitaler    Prolapse    der    Rectalmucosa,"    etc.,    Cetitralh.    f. 

Gyndlc.,  vol.  xx,  p.  759,  1896. 
Treves:    "Intestinal  Obstructions,"  p.  141,  1899. 

Tuttle:    "Operation  for  Procidentia  Recti,"  Medical  News,  Feb.  27,  1887. 
Urbane:    "Wire  Treatment  of  Prolapse,"  Jour.  Amer.  Med.  Assoc,  vol.  xxxiv, 

p.  1191,  1900. 
Van  Buren:    "Prolapse,"  "Diseases  of  the  Rectum  and  Anus,"  p.  85,  1882. 


CHAPTER  XXVI 

HISTORY,    CLASSIFICATION,    ETIOLOGY,  AND   PATHOLOGY 
OF  EXTERNAL  AND  INTERNAL  HEMOR- 
RHOIDS (PILES) 

HISTORY 

The  term  hemorrhoids  is  derived  from  the  Greek  aliio^^oog 
(flowing  with  blood),  which  is  compounded  from  atfia  (blood) 
and  poia  (a  flow).  It  was  originally  used  by  the  Greeks  to 
denote  a  hemorrhage  from  the  veins  of  the  rectal  portion  of 
the  large  intestine,  and  Galen  interpreted  it  to  mean  a  passive, 
and  not  an  active,  flow.  The  word  pile  is  from  the  Greek, 
nl^oc,  (Latin,  pila),  a  ball  or  globe.  The  two  words  as  now 
used  are  synonymous,  and  appHed  to  tumors  within  the  lower 
rectum  which  are  covered  with  mucosa  and  may  or  may  not 
bleed;  again,  they  are  also  employed  to  designate  vascular  or 
integumentary  tumors  located  at  the  anal  margin.  It  is  evi- 
dent, therefore,  that  it  is  impossible  to  give  a  satisfactory 
definition  of  hemorrhoids,  because  the  tumors  may  differ  so 
widely  in  their  location,  clinical  characteristics,  and  structure. 
The  following,  however,  applies  in  most  cases : — 

Hemorrhoids  (piles)  are  varicose  tumors  involving  the 
veins  and  capillaries  of  the  mucosa  and  subniucosa  of  the  lozver 
rectum,  characterized  by  a  tendency  to  bleed  and  protrude  (Plate 
XXII  and  Fig.  137). 

The  author  agrees  with  Bodenhamer  that  there  is  no  dis- 
ease within  the  whole  range  of  medical  literature  which  has  a 
more  ancient  history  or  a  more  conspicuous  sacredness  than 
hemorrhoids,  frequent  mention  of  them  having  been  made  in 
the  Bible,  ten  centuries  before  the  Grecian  era  or  time  of 
Hippocrates.  Moses  made  the  first  reference  to  hemorrhoids 
in  Deuteronomy,  xxviii,  2Y,  where  the  following  threat  of  pun- 
ishment for  disobedience  is  expressed :  "The  Lord  will  smite 
thee  with  the  botch  of  Egypt  and  with  the  emerods."  Again, 
in  I  Samuel,  v,  9,  it  is  recorded  that  the  men  of  Ashdod,  Ekron, 
and  Gath  were  afflicted :  "And  he  smote  of  the  city,  both  small 
and  great,  and  they  had  emerods  in  their  secret  parts."  And 
Psalm  Ixxviii,  66,  reads:  "And  he  smote  his  enemies  in  the 
(408) 


S«ii^ 


^.A'*"* 


-^ 


PLATE  XXIL— PROTRUDED  INTERNAL  HEMORRHOIDS  WITH 
PROLAPSED  MUCOSA. 


EXTERNAL  AND  INTERNAL  HEMORRHOIDS  -  409 

hinder  parts;    he  put  them  to  a  perpetual  reproach."     The 
Greek    physicians    interpreted    the    BibHcal    emerods    (hemor- 
rhoids) to  denote  a  hemorrhage  from  the  rectum;   the  modern 
commentators  differ  in  their  interpretations  of  the  term,  some 
holding  that  it  signified  a  hemorrhage,  and  others  believing  that 
there  was  both  hemorrhage  and  protrusion  of  the  bowel.     Be- 
cause of  the  punishment  threatened  by  Moses  upon  the  Jews, 
some  writers,  especially  Bernard  Gordon  in  the  thirteenth  cent- 
ury, have  held  that  the  disease  has  become  hereditary  among 
the  Jews,  and  that  it  is  therefore  most  common  among  them. 
Bodenhamer  holds  an  opposite  view,  and  maintains  that,  about 
three  centuries  after  Moses  had  threatened  the  Jews  with  the 
hemorrhoidal  plague,  God  visited  it  upon  the  Philistines  for 
having  taken  the  ark  of  the  Lord,  as  recorded  in  I  Samuel.    And 
when  the  Philistines  sought  their  priests  and  asked  what  they 
must  do  to  obtain  relief :    "And  they  said,  if  ye  send  away  the 
ark  of  the  Lord,  send  it  not  empty ;  but  in  any  wise  return  him 
a  trespass  offering,  then  ye  shah  be  healed"  (I  Samuel,  vi,  3). 
The  people  inquired:    "What  shall  be  the  trespass   offering 
which  we  shall  return  to  him?"   (verse  4).     The  priests  an- 
swered :    "Five  golden  emerods,  and  five  golden  mice,  accord- 
ing to  the  number  of  the  lords  of  the  Philistines ;  for  one  plague 
was  on  you  all,  and  on  your  lords"  (verse  4).     It  is  further 
recorded  that,  when  this  had  been  done,  the  stricken  men  were 
healed. 

Among  the  many  diseases  to  which  flesh  is  heir,  it  might 
be  said  that  there  is  none  of  more  common  occurrence,  more 
annoying,  or  more  acutely  painful  than  hemorrhoids.  Hemor- 
rhoids have  been  encountered  at  all  times,  in  all  climates,  in 
both  sexes,  at  all  ages  in  both  the  robust  and  the  debilitated, 
and  in  all  walks  of  life.  The  disease  occurs  more  frequently 
in  men  than  in  women,  and  is  extremely  rare  in  children. 

CLASSIFICATION 

Since  the  time  of  Hippocrates  hemorrhoids  (piles)  have 
been  classified  according  to  their  location  as: — 

1.  External  (covered  by  the  skin).  2.  Internal  (covered 
by  the  mucosa). 

The  external  variety  have  been  further  divided  into : — 

(a)  Thrombotic  (venous),  fh)  Cutaneous  (hypertrophied 
folds  of  skin) . 


410  DISEASES  OF  THE  RECTUM  AND  ANUS 

The  internal  variety  are  further  classified  according  to 
their  structure  as  : — 

(a)  Venous.  (h)   Capillary. 

Another  form  of  hemorrhoid  is  covered  by  both  skin  and 
mucous  membrane,  and  these  have  been  designated  externo- 
internal  or  combination  piles. 

ETIOLOGY 

The  etiologic  factors  entering  into  the  production  of  hem- 
orrhoids (piles)  are  so  numerous  and  varied  that  it  is  impossible 
in  a  work  of  this  character  to  consider  them  all.  For  this  reason 
only  the  more  prominent  and  common  causes  of  this  disease 
will  be  discussed. 

The  following  are  the  principal  predisposing  and  direct 
causes  of  hemorrhoids : — 

There  is  every  reason  to  believe  that  heredity  plays  a  part 
in  the  causation  of  this  disease.  This  theory  is  based  upon  the 
fact  that  persons  under  age  suffering  from  hemorrhoids  in  most 
cases  give  a  history  of  hemorrhoids  in  their  parents  and,  not 
infrequently,  in  their  grandparents. 

Owing  to  predisposing  habits  and  occupations,  the  male 
is  more  frequently  afflicted  with  hemorrhoids  than  the  female. 
Women  are  especially  predisposed  to  the  disease  during  preg- 
nancy because  of  encroachment  upon  the  rectum  by  the  uterus 
and  consequent  interference  with  the  circulation,  and  because 
of  the  straining  and  protrusion  of  the  parts  during  labor. 
Again,  a  retroverted  non-gravid  uterus  may  encroach  upon  the 
rectum  and  cause  hemorrhoids.  There  is  no  doubt  that  women 
suffer  from  hemorrhoids  more  frequently  than  statistics  show, 
because  many  of  them  through  false  modesty  hide  their  afflic- 
tion for  years  and  seek  no  relief. 

The  age  during  which  persons  are  most  disposed  to  hem- 
orrhoids is  between  twenty-five  and  fifty.  These  are  the  most 
active  years  in  the  life  of  the  male,  and  it  is  the  child-bearing 
period  in  the  life  of  the  female.  Again,  women  are  frequently 
disposed  to  hemorrhoids  during  the  menopause.  Children  are 
rarely  afflicted  with  this  disease.  The  author  has  treated  but 
few  cases  in  children :  one  of  these,  a  boy  of  12,  was  suffering 
from  protruding  internal  hemorrhoids;  another  was  a  little 
girl,   3  V2  years  old,   afflicted  with  two  small   venous   internal 


EXTERNAL  AND  INTERNAL  HEMORRHOIDS  411 

hemorrhoids  which  were  secondary  to  traumatic  stricture;  two 
others — one  a  boy  2  years  old  and  the  other  a  girl  of  18  months^ 
were  suffering  from  thrombotic  hemorrhoids  induced  by  strain- 
ing at  stool  during  constipation. 

Occupation  and  manner  of  living  frequently  play  an  impor- 
tant part  in  the  causation  of  hemorrhoids.  Hemorrhoids  are 
slightly  more  common  in  the  higher  classes  of  society  than  in 
the  lower.  This  is  because  the  well-to-do  usually  lead  seden- 
tary lives,  are  more  apt  to  be  inactive  and  irregular  in  their 
habits,  indulge  in  high-grade  wines  and  liquors,  and  hot,  highly- 
seasoned,  and  stimulating  foods.  In  the  lower  walks  of  life 
hemorrhoids  are  most  common  among  those  whose  occupa- 
tion is  arduous  and  compels  them  to  do  heavy  lifting,  or  to 
remain  on  their  feet,  or  sit  on  hard  and  unventilated  seats  for 
several  hours  at  a  time.  Railway  employees  are  particularly 
prone  to  hemorrhoids,  because  they  must  remain  in  the  upright 
position  for  hours  at  a  time,  take  meals  and  attend  to  the  calls 
of  Nature  at  irregular  intervals,  and  also  because  they  are  sub- 
jected to  the  constant  jarring  motion  of  the  train. 

In  the  author's  opinion,  climate  and  season  are  unimportant 
factors  in  the  causation  of  hemorrhoids,  and  this  undoubtedly 
is  the  case  in  the  United  States.  Some  authors  maintain  that 
hemorrhoids  are  more  common  in  tropic  countries  than  in 
colder  climates,  and  it  is  quite  probable  that  the  disease  is  sec- 
ondary to  the  straining  and  irritation  incident  to  dysentery  in 
hot  climates. 

The  injudicious  use  of  drastic  purgatives  and  enemata  tends 
to  produce  hemorrhoids,  owing  to  the  straining  and  irritation 
produced  by  them. 

Any  affection  of  the  bladder,  urethra,  or  intestine,  or  any 
tumor  of  the  abdominal  or  pelvic  organs,  prostate,  or  urethra, 
which  presses  upon  the  rectum,  obstructs  the  circulation  or 
induces  straining,  irritation,  or  inflammation,  may  result  in  a 
varicose  condition  of  the  lower  rectum.  Tight  lacing  may 
cause  this  condition  by  increasing  the  pressure  within  the  ab- 
domen and  pelvis,  and  thus  interfering  with  the  circulation  in 
the  rectum. 

Some  authors  maintain  that  spasmodic  or  involuntary  con- 
tractions of  the  sphincter-muscle  may  cause  hemorrhoids.  They 
argue  that  during  defecation  the  mucous  membrane  protrudes 
beyond  the  sphincter-muscle  and  is  caught  in  the  contraction; 


412  DISEASES  OF  THE  RECTUM  AND  ANUS 

this  causes  engorgement  of  the  vessels,  which,  when  often  re- 
peated, results  in  the  formation  of  piles. 

Owing  to  the  non-existence  of  valves  to  support  the  col- 
umn of  blood  in  the  rectal  veins,  the  upright  position  of  man 
may,  by  gravity  alone,  be  conducive  to  hemorrhoids.  This 
leads  to  a  varicose  condition  of  the  veins  and  venous  radicles 
of  the  lower  rectum. 

The  hemorrhoidal  plexus  of  enlarged  and  anastomosing 
veins  is  situated  in  the  lower  part  of  the  rectum,  and  from  it 
proceeds  the  "superior  hemorrhoidal  vein,"  which  returns  the 
blood  from  the  rectum  proper  to  the  portal  system.  This  vein 
and  its  branches  pass  upward  beneath  the  mucous  membrane 
for  a  distance  of  about  three  inches  (Y.62  centimeters),  then 
perforate  the  muscular  coat,  and  can  be  seen  on  the  outside 
of  the  bowel.  Verneuil  has  laid  much  stress  on  this  anatomic 
fact,  claiming  that  the  veins  pass  through  muscular  button-holes 
(Plate  XXIII),  which  have  the  power  of  contracting  around  them, 
closing  their  lumen  and  preventing  a  return  of  blood  to  the 
liver.  In  this  anatomic  arrangement,  he  believes,  is  to  be  found 
the  active  cause  of  internal  hemorrhoids. 

Since  the  blood  from  the  hemorrhoidal  plexus  is  returned 
to  the  liver,  it  is  easy  to  understand  how  obstructive  hepatic  dis- 
ease may  cause  a  varicose  condition  of  the  veins  in  the  lower 
rectum. 

Constipation  is  perhaps  the  most  frequent  cause  of  hemor- 
rhoids. When  defecation  is  deferred  for  a  considerable  time 
the  feces  accumulate  and  become  hard  and  nodular  and  diffi- 
cult to  expel.  If  this  large,  hard  mass  is  retained  in  the  rectum, 
it  presses  upon  the  vessels,  interferes  with  the  circulation,  and 
by  bruising  the  vessels  may  induce  a  phlebitis.  When  the  hard- 
ened feces  are  expelled,  straining  is  intense,  the  mass  closes  the 
vessel  above  by  pressure  and  forces  the  blood  downward  into 
the  veins,  producing  dilatation ;  when  the  force  is  sufficient,  one 
or  more  of  the  small  veins  near  the  anal  outlet  may  rupture 
and  cause  a  vascular  tumor  beneath  the  mucosa  or  skin. 


PATHOLOGY 

The  classification  of  hemorrhoids  (piles)  into  internal  and 
external  is  more  important  from  a  clinic  than  from  a  pathologic 
stand-point,  because  the  changes  which  occur  in  the  structures 


PLATE  XXIII.— 8B0WING   THE   VASCULAR  SUPPLY   OF 

INTERNAL    HEMORRHOIDS. 
A,  Superior    hemorrhoidal    Veins.     B,  Middle   hemorrhoidal   veins.     C, 
Inferior  hemorrhoidal  veins.    D,  Hemorrhoidal  plexus  hy  removal  of  the  mucous 
membrane.     E,  Protruding  internal  hemorrhoids  covered  by  mucosa. 


EXTERNAL  AND  INTERNAL  HEMORRHOIDS  413 

during  the  formation  of  both  varieties  of  tumor  are  similar  in 
many  respects.  In  order  to  follow  these  changes  it  is  necessary 
to  have  a  comprehensive  understanding  of  the  venous  circu- 
lation of  the  lower  rectum  (Plate  XXIII). 

The  small  branches  of  the  superior  hemorrhoidal  veins 
anastomose  with  similar  branches  of  the  inferior  hemorrhoidal 
vein  in  the  lower  inch  and  a  half  (4.8  centimeters)  of  the  rec- 
tum, in  and  about  Morgagni's  columns.  The  importance  of 
this  anastomosis  will  be  appreciated  when  it  is  understood  that 
these  intercommunicating  venous  radicles  are  the  connecting 
links  which  here  unite  the  portal  and  systemic  systems,  and  that 
these  radicles  are  the  usual  site  of  hemorrhoidal  degeneration. 
The  larger  veins  from  this  plexus  of  small  anastomosing  veins 
pass  directly  upward  beneath  the  mucosa  for  about  three 
inches  (7.62  centimeters),  where  they  find  an  exit  through 
button-holes  in  the  muscular  coat  and  unite  to  form  the  superior 
hemorrhoidal  (Plate  XXIII),  from  which  the  blood  passes  by 
way  of  the  inferior  mesenteric  vein  to  the  liver.  These  veins  have 
no  valves,  and  are  but  poorly  supported  by  the  loose  tissues. 

It  is  not  surprising,  then,  that  the  radicles  of  these  veins 
entering  into  the  formation  of  the  plexus  in  and  about  Mor- 
gagni's columns  become  dilated  and  diseased ;  the  upright 
position  of  man  and  the  tendency  of  the  unsupported  blood- 
column  to  fall  of  its  own  weight  might  alone  produce  the  vari- 
cose condition  of  the  venous  radicles ;  more  frequently,  how- 
ever, it  is  the  result  of  some  interference  with  the  circulation 
of  the  lower  rectum,  such  as  occurs  in  constipation,  obstructive 
disease  of  the  liver,  pregnancy,  or  other  cause  described  in 
"Etiology." 

On  close  examination  an  internal  venous  pile  in  its  in- 
cipiency  will  be  found  to  consist  of  a  fold  of  mucosa  in  which  is 
a  number  of  diminutive  pyriform  dilatations  of  the  venous  rad- 
icles. If  at  this  stage  the  cause  is  not  removed  and  the  degener- 
ative process  stopped,  the  dilatations  become  more  prominent 
and  other  minute  veins  become  involved.  The  varicose  con- 
dition extends  gradually  upward  to  involve  the  branches  of  the 
superior  hemorrhoidal  vein  and  downward  to  those  of  the  in- 
ferior hemorrhoidal,  including  those  in  the  mucosa,  submucosa, 
and  in  rare  instances  those  in  the  musculature.  As  the  dila- 
tation of  these  vessels  is  more  marked,  the  conformation  of 
one  or  more  tumors  becomes  evident. 


414  DISEASES  OF  THE  RECTUM  AND  ANUS 

A  section  will  now  show  that  the  tumor  is  composed  of 
numerous  dilated  and  diseased  veins  (Fig.  136),  the  walls 
of  which  may  be  thickened  from  an  increase  in  the  connective- 
tissue  element,  or  they  may  be  thinned  and  consist  only  of  a 
delicate  layer  of  connective  tissue.  Quenu  and  Hartmann  hold 
that  the  thickening  of  the  walls  is  not  due  to  hyperplasia  of 
the  muscular  tissue  which  may  remain  unchanged,  but  to  an 
increase  in  the  connective  tissue  alone,  or  to  proliferation  of 
embryonal  tissue  with  a  budding  of  the  intima  into  the  lumen 
of  the  vessel.  In  some  cases  there  may  be  a  material  increase 
in  the  number  of  smaller  veins  and  their  radicles  without  any 
apparent  dilatation  in  the  earlier  stages  of  the  disease. 


Fig.  136. — Cross-section  of  Internal  Hemorrhoids  (Schematic). 

As  the  degenerative  process  proceeds,  the  hemorrhoidal 
formation  increases  in  size  and  density,  depending  largely  upon 
increased  formation  of  connective  tissue,  which  may  take  place 
in  the  walls  of  the  veins,  in  the  intervenous  spaces,  and  between 
the  tumor  and  the  muscular  coat.  Some  of  the  veins  may  now 
become  obliterated  as  a  result  of  an  endophlebitis  or  the  en- 
croachment of  connective  tissue  upon  their  lumina.  Again, 
the  veins  may  become  cavernous  and  thrombi  may  form,  which 
become  organized  and  transformed  into  fibrous  tissue,  thus 
obliterating  the  vessel  (Plate  XXIV).  Quenu  and  Hart- 
mann hold  that  the  most  characteristic  changes  are  proliferat- 
ing endophlebitis  in  the  veins  and  transformation  of  the  rectal 
wall  into  cavernous  tissue. 


EXTERNAL  AND  INTERNAL  HEMORRHOIDS 


415 


While  the  venous  element  always  predominates,  each  tu- 
mor has  an  arterial  supply.  The  structure  of  the  arteries  is, 
however,  but  slightly  altered  in  the  hemorrhoidal  degeneration. 

Some  authors  maintain  that  there  is  a  form  of  arterial  hem- 
orrhoids because  of  the  fact  that  in  some  cases  the  mucosa  is 
highly  colored,  pulsations  can  be  felt,  and  spurting  occurs. 
Cripps  believes  that  the  spurting  in  such  cases  is  due  to  the 
blood  being  forced  by  the  powerful  abdominal  muscles  as  a 
regurgitant  stream  through  a  rupture  in  the  vein.  Quenu  and 
Hartmann  have  demonstrated  to  their  satisfaction  by  differ- 
ential injections  and  dissections  that  there  is  no  such  thing  as  an 
arterial  pile.     The  same  authors,  who  have  made  extensive  in- 


^^^ 


Fig.  137. — Protruding  Internal  Hemorrhoids  (Schematic). 


vestigations  along  this  line  hold  that  in  these  cases  the  veins 
become  metamorphosed  into  a  sort  of  cavernous  erectile  tissue,  and 
some  of  the  veins  assume  the  structure  and  functions  of  arteries 
perhaps,  but  the  original  arteries  remain  unchanged  or  tend  toward 
atrophy, 

Earle,  of  Baltimore,  in  discussing  the  extent  to  which  the 
arteries  are  involved  as  shown  by  his  original  experiments, 
says :  "The  arteries  in  places  seem  to  have  hypertrophied  mus- 
cular coats  and  thickened  membrana  limitans  interna;  also  en- 
darteritis obliterans ;  calcification  of  arterial  wall ;  connective 
tissue  compressed  and  atrophied  by  ectasis  of  veins." 

When  hemorrhoidal  tumors  attain  such  size  as  to  project 


416  DISEASES  OF  THE  RECTUM  AND  ANUS 

into  the  lumen  of  the  bowel,  they  are  soon  made  to  pfoirude 
as  a  result  of  straining  and  downward  pressure  exerted  during 
defecation.  At  first  they  return  spontaneously,  but  later  on 
they  require  to  be  replaced,  and,  when  the  sphincter  becomes 
relaxed,  they  protrude  most  of  the  time  (Plate  XXII  and  Fig. 
137).  As  a  result  of  irritation  from  the  feces  and  handling,  to- 
gether with  frequent  attacks  of  phlebitis,  periphlebitis,  and  the 
formation  of  fibrous  tissue,  the  mucosa  over  the  tumors  in  most 
cases  becomes  thickened  and  less  mobile  and  elastic  than 
normal.  In  exceptional  cases,  however,  the  mucous  membrane 
may  be  pliable,  spongy,  and  appear  not  unlike  the  surface  of  a 
strawberry.  The  prolonged  irritation  and  infection  not  infre- 
quently produce  erosion  and  eventually  ulceration  of  the  tumor, 
which  may  lead  to  frequent  slight  or  profuse  hemorrhages. 
Bleeding  from  the  superficial  capillaries  is  slight,  but,  when  the 
ulceration  is  sufficiently  deep  to  injure  the  dilated  vessels,  the 
bleeding  is  usually  profuse  and  sometimes  fatal. 

A  Capillary  Hemorrhoid  consists  in  dilatation  of  the  superficial 
capillaries  of  the  mucous  membrane,  the  vessels  of  the  submucosa 
not  being  involved.  The  areas  involved  are  fiat,  project  slightly 
above  the  surrounding  mucosa,  are  bright  red  in  color,  soft 
and  spongy,  and  have  a  strazvberry-like  or  nevoid  appearance. 
Capillary  hemorrhoids  are  extremely  rare,  may  be  single  or 
multiple  and  vary  from  a  quarter  of  an  inch  (0.63  centimeter) 
to  an  inch  (2.64  centimeters)  in  size.  The  hemorrhage  is  of  an 
oozing  character  and  constant,  but  slight.  They  may  appear 
alone  or  in  conjunction  with  the  venous  variety.  They  rarel)' 
protrude,  and  cause  but  little  pain. 

Thrombotic  Hemorrhoids  may  be  due  to  an  extension  of  the 
varicose  condition  of  the  hemorrhoidal  plexus,  or  they  may 
have  an  independent  origin  in  the  small  veins  at  the  anal  mar- 
gin coming  from  the  inferior  hemorrhoidal.  These  perianal 
veins  mav  rupture  or  become  varicose,  resulting  in  the  forma- 
tion of  the  typic  thrombotic  hemorrhoid.  This  variety  of  piles 
is  characterized  by  sharply-defined,  firm,  oval  tumors  of  a  livid 
color,  situated  at  the  anal  margin,  and  which  look  not  unlike 
bullets  beneath  the  skin.-  The  form  and  color  of  the  tumor  is 
due  to  the  presence  of  a  clot  of  blood.  If  the  pile  is  seen  before 
the  clot  has  formed,  it  is  soft,  pliable,  and  the  color  of  the  sur- 
rounding skin.  There  has  been  considerable  controversy  as  to 
whether  the  clot  is  formed  in  a  dilated  vein  or  in  the  tissues  out- 


EXPLANATION  OF  PLATE  XXIV 


At  the  Tipper  margin  the  dark,  irregular  line  repre- 
sents the  epidermia,  which,  on  the  right,  one  and  one- 
half  inches  (3.8  centimeters)  lower  down,  thins  out  into 
the  stratified  mucous  membrane  of  the  anus.  This 
shortly  disappears,  having  been  lost  in  sectioning,  but 
two  inches  (5.08  centimeters)  farther  down  the  mucous 
membrane  of  the  rectum  appears,  bounded  internally  by 
the  muscularis  mucosae,  which  is  seen  as  a  thin,  darkish 
line. 

Beneath  the  epidermis,  above  is  a  mass  of  dense  con- 
nective tissue  traversed  by  large  numbers  of  distended 
blood-vessels,  and  beneath  this  are  enormously  dilated 
venous  channels  filled  with  dark  masses  of  coagulated 
blood.  There  ia  no  evidence  of  actual  hemorrhage,  the 
coagulated  masses  being  obviously  contained  within 
definite  channels. 


FLUTE  XXIU 


Microscopic Hppearancs  of  Interna.1  Homorrlioid,     [MagrAficatian,  ID,-] 


EXTERNAL  AND  INTERNAL  HEMORRHOIDS  417 

side  after  the  vein  has  been  ruptured  and  extravasation  of 
blood  has  occurred.  The  author  has  carefully  dissected  many 
of  these  tumors  and  has  had  microscopic  examinations  made 
of  many  specimens,  and  he  is  convinced  that  the  clot  may 
form  either  within  the  vein  (Plate  XXIV)  or  in  the  tis- 
sue external  thereto  (Plate  XXV).  It  is  probable  that, 
when  the  clot  requires  several  days  to  form,  it  is  intra- 
venous; but,  when  it  appears  suddenly  after  straining  at 
stool,  it  is  likely  that  a  diseased  vein  has  been  ruptured 
and  a  clot  formed  in  the  adjacent  tissue.  When  the  clot 
has  become  partially  organized,  it  is  not  difficult  to  mistake 
the  capsule  formed  around  it  for  the  dilated  vein-wall.  In 
either  case  when  the  clot  is  enucleated  it  leaves  a  fairly 
smooth  surface.  Such  a  clot  may  be  entirely  absorbed  after 
a  few  days  or  weeks,  or  the  skin  over  it  may  become 
ulcerated  as  the  result  of  irritation  and  the  clot  extruded; 
again,  the  clot  may  become  infected  by  the  pyogenic  bacteria 
common  to  this  locality,  and  terminate  in  a  marginal  abscess 
and  fistula. 

Cutaneous  Hemorrhoids  are  simple  hypertrophied  tags  of 
skin.  Properly  speaking,  they  should  not  be  classed  as  hemor- 
rhoids, because  of  the  absence  of  characteristic  bleeding  and 
varicose  condition  of  the  veins.  This  form  of  pile  is  frequently 
secondary  to  the  thrombotic  variety.  As  a  result  of  inflamma- 
tion and  irritation  induced  by  contraction  of  the  sphincter, 
there  occurs  an  hyperplasia  of  the  skin  covering  the  clot ;  this, 
together  with  stretching  of  the  skin  caused  by  the  clot  be- 
neath it,  may  produce  the  cutaneous  pile.  These  cutaneous 
hypertrophies  are  often  induced  by  stretching  and  bruising  of 
the  anal  radial  folds  of  skin  during  defecation,  which,  together 
with  the  injury  and  stretching  of  the  folds  incident  to  sitting 
or  walking,  frequently  causes  them  to  become  inflamed  and 
finally  hypertrophied.  They  are  irregular  in  shape,  single  or 
multiple,  from  a  quarter  of  an  inch  to  an  inch  (0.63  to  2.54  cen- 
timeters) in  length,  usually  the  color  of  the  normal  skin,  and 
are  not  very  sensitive.  During  an  inflammatory  attack  they 
may  become  red,  swollen,  edematous,  extremely  sensitive,  and 
excite  the  sphincter  to  frequent  spasmodic  contraction. 

See   Literature  on  Hemorrhoids   (Piles),  page  471. 

27 


CHAPTER  XXVII 

SYMPTOMS,  DIAGNOSIS,  AND  TREATMENT  OF  EXTERNAL 
HEMORRHOIDS  (PILES) 

SYMPTOMS 

Thromljotic  Hemorrhoids  (Piles)  usually  occur  in  robust  per- 
sons. Their  onset  is  sudden,  and  caused  by  the  rupture  of  one 
or  more  small  veins  during  the  expulsion  of  hardened  feces. 
They  are  usually  single,  but  occasionally  there  may  be  two  or 
more ;  are  located  at  the  muco-cutaneous  junction,  and  vary  in 
size  from  the  diameter  of  a  millet-seed  to  that  of  a  cherry.  They 
are  ovoid  in  shape,  livid  or  dark  blue  in  color,  and  appear  and 
feel  like  bullets  or  small  shot  beneath  the  skin  (Plate  XXV). 
At  first  they  cause  a  sensation  of  swelling  at  the  anal  margin; 
as  the  clot  becomes  larger  and  harder  there  is  a  feeling  of  the 
presence  of  a  foreign  body  in  the  lower  part  of  the  anal  canal. 
This  is  resented  by  the  sphincter,  which  spasmodically  con- 
tracts, occasionally  at  first,  producing  a  drawing  sensation ; 
later  the  contractions  become  more  frequent  and  of  longer 
duration,  and  intense  suffering  is  experienced  by  the  almost 
constant  constriction  of  the  pile. 

The  suffering  caused  by  a  thrombotic  hemorrhoid  becomes 
so  intense  that  the  patient  is  unable  to  sleep  or  obtain  relief, 
no  matter  what  position  may  be  assumed.  Because  of  tenes- 
mus, irritation  of  the  feces,  and  sphincteralgia,  they  soon  be- 
come highly  inflamed  and  very  sensitive.  Even  if  not  treated, 
the  clot  may  be  absorbed ;  occasionally,  however,  the  tumors 
become  ulcerated  as  the  result  of  continued  irritation,  infection 
of  the  clot  takes  place,  and  marginal  abscess  terminating  in 
fistula  results. 

Cutaneous  Hemorrhoids  (Piles)  consist  of  hypertrophied  pro- 
longations of  the  skin,  and  are  frequently  secondary  to  the  ab- 
sorption of  the  clot  in  thrombotic  hemorrhoids  where  the  skin 
is  bruised  and  stretched.  They  may  be  single  or  multiple ;  are 
usually  chronic,  irregular  in  shape,  of  variable  size,  and,  except 
when  acutely  inflamed,  are  the  color  of  the  skin.  Cutaneous 
hemorrhoids  cause  less  suffering  than  the  thrombotic  variety; 
in  fact,  they  may  exist  for  years  without  causing  the  patient 
(418) 


■J-  y~ 


y 


PLATE  XXV.— EXTERNAL  THROMBOTIC  HEMORRHOID. 


EXTERNAL  HEMORRHOIDS  419 

any  trouble,  providing  proper  care  is  observed.  But  when 
bruised  from  any  cause,  such  as  a  kick  or  fah,  sitting  on  a  hard 
seat,  stretching  of  the  parts  during  defecation,  etc.,  or  when 
irritated  by  acrid  discharges  from  the  rectum  or  vagina,  they 
may  become  inflamed  and  produce  much  pain  and  annoyance. 
When  the  inflammatory  process  is  subacute,  the  pain  is  shght, 
and  the  patient  complains  of  heat  and  fullness  about  the  anus 
and  discomfort  during  defecation. 

When  acutely  inflamed,  cutaneous  piles  become  greatly 
swollen,  highly  colored,  edematous,  painful,  extremely  sensi- 
tive to  the  touch,  cause  frequent  spasmodic  contractions  of  the 
sphincter-muscle,  and  may  result  in  the  formation  of  an  ab- 
scess. The  pain  is  usually  confined  to  the  anal  region,  but  may 
be  reflected  up  the  back,  down  the  limbs,  or  to  neighboring 
organs. 

DIAGNOSIS 

The  diagnosis  of  external  hemorrhoids  (piles)  is  easily 
made.  The  thrombotic  variety  is  characterized  by  its  smooth, 
globular  shape ;  bluish  tint,  hard  feel,  and  sudden  onset. 
Cutaneous  hemorrhoids  are  marked  by  their  irregular  tag-like 
appearance,  flesh-like  color,  softness,  and  chronicity.  On  the 
other  hand,  internal  hemorrhoids  may  be  differentiated  from 
the  external  variety  by  their  higher  internal  attachment,  purple 
color,  and  by  the  fact  that  they  are  covered  with  mucous 
membrane. 

TREATMENT 

The  treatment  of  external  hemorrhoids  (piles)  is  simple 
and  when  properly  carried  but  is  universally  successful.  It 
should  be : — 

1.  Non-operative.  2.  Operative. 

The  Non-operative  Treatment  of  both  varieties  of  external 
hemorrhoids  is  the  same.  In  all  cases  rest  in  the  recumbent  posi- 
tion should  be  insisted  upon.  The  diet  should  be  regulated, 
and  highly-seasoned  foods  and  stimulants — such  as  tobacco, 
whisky,  wine,  etc. — discarded.  A  daily  semisolid  stool  should 
be  secured  by  the  use  of  small  doses  of  saline  cathartics,  Cara- 
baha,  Hunyadi,  Freidrichshall,  or  other  reputable  laxative 
mineral  water.  If  necessary,  the  liver  may  be  stimulated  with 
calomel  or  blue  pill.  Frequent  cleansing  of  the  parts  with  some 
weak  antiseptic  solution  or  Castile  soap  and  water  is  essential, 


420  DISEASES  OF  THE  RECTUM  AND  ANUS 

and  to  allay  the  pain,  reduce  inflammation,  and  soothe  the 
sphincter-muscle,  cold  or,  if  preferred,  hot  applications  may  be 
kept  constantly  on  the  affected  parts.  Hot  stupes  or  poultices 
of  flaxseed,  bread,  etc.,  give  instantaneous  relief  in  most  cases, 
while  in  others  it  is  necessary  to  resort  to  soothing  lotions, 
ointments,  or  suppositories.  The  lead-and-opium  wash,  made 
as  follows,  is  always  reliable : — 

IJ  Liquor  plumbi  subacetatis 3iv  151 

Tincturae  opii   3iiss  101 

Aquae  destillatse q.  s.  ad  §iv  120 

Sig. :    Apply  constantly  ice  cold  on  cotton  or  gauze. 

The  following  ointments  and  lotions  used  freely  within  the 
anal  canal  and  to  the  hemorrhoids  are  effective  in  relieving  pain, 
reducing  inflammation,  and  diminishing  sphincteralgia : — 

IJ  Ungt.  stramonii 3iss  6 

Ungt.  belladonnge   Siiss  10 

Ungt.  acidi  tannic!  5ss  15 

M.    Sig.:    Apply  in  and  outside  the  anus.     (Gant.) 

IJ  Morphinse  sulphatis   gr.  iij         195 

Hydrargyri  chloridi   gr.  xij 

Vaselini    §j  31 

M.     Sig.:    Apply  freely  within  the  anus  and  to  the  piles.     (Gant.) 

IJ  Bismuthi  subnitratis   3ij 

Hydrargyri  subchloridi   3j 

Morphinse  acetatis   gr.  iv        27 

Vaselini    Bj  31 

M.     Sig.:    Use  freely  as  local  application.     (Allingham.) 

I^  Cocainae  hydrochloridi gr.  v         1325 

Ext.  belladonnse, 

Ext.  opii, 

Ext.  aeoniti, 

Ext.  stramonii  aa  3ij  SI 

Glycerini    3ss  2 

M.     Sig.:    Apply  on  cotton  or  lint  continuously.     (Yount.) 

Ball  prefers  a  mixture  of  the  extract  of  belladonna  and 
glycerin  smeared  over  the  parts  and  followed  shortly  by  warm 
stupes. 

An  acute  attack  of  external  hemorrhoids  can  usually  be 
relieved  in  a  few  days  by  observing  the  above  non-operative  treat- 
ment;   but,  when  the  piles  become  inflamed  from  slight  causes, 


EXTERNAL  HEMORRHOIDS  421 

it  is  best  to  resort  to  operative  procedures  at  the  earliest  oppor- 
tunity. 

The  Operative  Treatment  of  external  hemorrhoids  of  either 
variety  is  simple,  and  but  a  short  time  is  necessary  to  effect  a 
cure.  The  operations  are  unattended  by  danger,  require  no 
general  anesthetic,  can  be  done  in  a  very  few  minutes,  and  are 
followed  by  little  post-operative  pain.  It  is  not  necessary  for 
these  patients  to  remain  in  bed  more  than  a  few  hours.  When 
complicated  by  other  conditions  necessitating  divulsion  of  the 
sphincter  and  secondary  operation,  it  is  best  to  give  a  general 
anesthetic. 

The  removal  of  the  tumors  causes  but  little  pain  when 
they  are  properly  injected  with  sterile  water  or  a  weak  solution 
of  eucaine  or  cocaine,  or  frozen  with  the  ether-spray,  ethyl 
chloride,  or  liquid  air.  The  author  prefers  a  solution  of  eucaine ; 
in  his  practice  this  has  proven  most  effective;  it  can  be  steril- 
ized, and  is  followed  by  fewer  unpleasant  effects. 

The  technic  of  the  operation  for  thrombotic  piles  is  as  fol- 
lows :  After  the  parts  have  been  thoroughly  cleansed  and  the 
piles  anesthetized,  the  buttocks  are  held  apart  by  an  assistant. 
The  operator  transfixes  the  tumor  at  its  base  with  a  slender, 
sharp-pointed,  curved  bistoury,  which  is  made  to  cut  its  way 
out,  laying  the  tumor  open  from  one  side  to  the  other.  The 
clot  is  then  thoroughly  removed  with  a  curette  and  the  rent  in 
the  vessel  cauterized.  The  cavity  should  be  packed  with  a 
small  piece  of  gauze  to  fortify  against  hemorrhage  and  to 
secure  drainage,  thereby  preventing  the  formation  of  a  new 
clot. 

Cutaneous  Hemorrhoids  are  operated  upon  as  follows :  Each 
tumor  is  in  turn  grasped  with  a  pair  of  strong  forceps  and 
snipped  off  with  scissors,  or  removed  by  eUiptic  incision  with  a 
knife.  The  wounds  left  may  be  closed  with  catgut  sutures  or 
dressed  with  gauze  and  allowed  to  heal  by  granulation.  When 
the  wounds  are  small  suturing  is  unnecessary,  but  when  of  con- 
siderable size,  much  after-pain  can  be  prevented  and  a  more 
rapid  cure  obtained  by  closing  them  and  securing  primary 
union.  When  the  tumors  are  large  and  swollen,  care  must  be 
taken  not  to  remove  too  much  tissue;  otherwise  extensive 
wounds  are  left  which  cause  increased  suffering  and  a  longer 
convalescence  and,  when  healed,  may  result  in  a  partial  or  com- 
plete stricture. 


422  DISEASES  OF  THE  RECTUM  AND  ANUS 

Much  after-pain  can  be  forestalled  by  placing  in  the  rectum 
a  suppository  containing  V2  grain  (0.03  gram)  of  opium  or 
cocaine  before  either  of  the  above  operations  is  performed. 

The  Post-operative  Treatment  of  external  hemorrhoids  is 
quite  sim.ple.  It  consists  in  keeping  the  patients  quiet,  cleans- 
ing the  parts  frequently,  and  securing  a  daily  soft  stool. 

ILLUSTRATIVE  CASES 

Case  XXVIII.  External  Hemorrhoids  (Thrombotic  Variety).  — Early 
one  morning  I  was  called  to  Dr.  G.,  who  was  suffering  from  an  acute  attack 
of  piles.  I  found  the  doctor  groaning  and  rolling  from  one  side  of  the  bed 
to  the  other.  On  inquiry  the  patient  said  he  had  piles.  I  requested  him  to 
assume  the  Sims  position,  and  proceeded  to  make  an  examination,  which 
revealed  the  presence  of  two  thrombotic  hemorrhoids  closely  hugging  the 
anus  at  the  muco-cutaneous  junction.  They  were  round,  hard,  dark  blue  in 
color,  and  felt  and  looked  like  bullets  beneath  the  skin.  The  sphincter 
was  tightly  contracted  about  them.  The  patient  was  informed  that  the 
quickest  way  to  get  relief  was  to  have  the  piles  transfixed  with  a  knife 
and  the  clots  turned  out.  He  said  he  was  willing  to  do  anything  to  get 
relief.  A  solution  of  cocaine  (6  per  cent.)  was  applied  to  the  tumors  for  five 
minutes  to  deaden  the  pain;  then,  with  a  sharp-pointed,  curved  bistoury,  each 
pile  was  incised  in  turn  and  the  clots  scraped  out  with  a  small  curette,  caus- 
ing very  little  pain.  Relief  was  so  great  that  the  patient  dozed  off  to  sleep 
M-ithin  fifteen  minutes  after  the  operation  was  completed.  The  edges  of  the 
incision  were  kept  apart  by  a  piece  of  gauze  inserted  into  the  pile  as  drainage 
and  to  prevent  refilling.  The  next  morning  he  was  able  to  make  his  calls 
with  comfort.    He  has  never  had  a  relapse. 

Case  XXIX.  External  Hemorrhoids  (Thrombotic  Variety).  —  Dr.  S. 
called  at  my  office  to  be  examined  for  rectal  disease.  He  complained  of  con- 
siderable pain,  spasm  of  the  sphincter,  and  sensations  of  heat  and  fullness 
about  the  anal  margin.  Some  hours  before  he  first  noticed  that  there  was 
something  wrong  immediately  after  defecation.  Examination  revealed  a  large, 
hard,  bluish-looking  tumor  at  the  anal  margin.  A  diagnosis  of  thrombotic 
pile  was  made,  the  tumor  incised,  and  the  clot  curetted  out.  It  was  suggested 
that  it  would  be  best  for  him  to  remain  quietly  in  bed  for  the  remainder  of 
the  day,  but  he  replied  that  urgent  business  rendered  this  impossible.  The 
next  morning  I  was  not  much  surprised  when  the  doctor  walked  into  the 
office  and  remarked  that  the  pile  had  refilled  and  was  as  painful  as  before. 
He  was  again  placed  on  the  table  and  the  hemorrhoid  incised  as  before,  and 
a  small  pledget  of  cotton  inserted  and  left  in  the  incision.  He  immediately 
returned  to  his  residence,  where  he  remained  quiet  for  several  hours,  when 
lie  resumed  his  usual  duties. 

Case  XXX.  External  Hemorrhoids  (Cutaneous  Variety).— I  was  called 
in  consultation  to  see  Mr.  W.  C.  who  was  suffering  from  piles  and  gave  the 
following  history:  Aged  42;  fireman;  had  always  been  healthy  until  his 
present  illness,  except  that  he  was  badly  constipated  and  had  to  take  a 
catliartic  to  move  his  bowels.  He  was  irregular  in  his  habits  and  drank  quite 
freely  of  alcoholic  stimulants.     He  first  noticed  the  presence  of  piles  a  week 


EXTERNAL  HEMORRHOIDS  423 

before  he  came  to  me.  He  complained  of  pain,  heat,  and  swelling  about  the 
anus,  and  said  that  for  two  nights  he  had  been  unable  to  sleep  on  account  of 
the  jerking  of  the  anus.  He  was  extremely  nervous,  and  his  face  was  pinched 
in  evidence  of  his  suffering.  The  pain  was  of  a  drawing,  burning  character. 
He  was  placed  upon  a  lounge  in  a  good  light  and,  on  separating  the  buttocks, 
two  very  large,  external,  cutaneous  piles  were  seen.  They  were  acutely  in- 
flamed, red,  and  very  sensitive;  he  was  informed  that  an  operation  was  the 
quickest  and  most  satisfactory  way  to  get  rid  of  them.  He  objected  to  hav- 
ing any  cutting  done,  and  said  that  time  was  no  object.  A  saline  cathartic 
every  morning  to  insure  a  free  action,  and  hot  flaxseed  poultices  moistened 
with  laudanum  to  be  kept  constantly  applied  to  the  tumors  were  ordered. 
Within  an  hour  the  patient  was  fairly  comfortable.  During  the  night  he 
.awoke  a  number  of  times  when  the  sphincters  contracted,  but  soon  went  to 
deep  again.  On  the  following  morning  the  tumors  were  less  sensitive  and 
very  much  reduced  in  size,  and  he  wanted  to  sit  up.  He  was  requested  to 
remain  in  bed,  and  the  poultices  were  continued  for  twenty-four  hours  longer, 
when  they  were  discarded  and  the  ice-bag  substituted.  On  the  fourth  day 
from  the  time  treatment  was  instituted  the  inflammation  subsided  and  the 
piles  had  shriveled  up.  They  were  nothing  more  than  hypertrophied  folds  of 
skin,  which  could  be  handled  without  causing  any  pain. 

Case  XXXI.  External  Hemorrhoids  Complicated  with  Fissure.  —  A 
friend  of  mine  called  me  to  see  his  wife,  who  was  suffering  from  some  rectal 
trouble.  She  gave  the  following  history:  Aged  32  years;  nervous  tempera- 
ment; family  history  good.  She  had  always  been  well  except  habitual  con- 
stipation, which  sometimes  caused  dizziness  and  sick  headache.  She  had  never 
suffered  from  any  rectal  trouble  until  her  present  attack,  which  dated  back 
to  the  previous  week,  when,  during  stool,  much  straining  was  required  to 
expel  the  feces,  which  were  large,  round,  and  nodular.  She  felt  a  sharp, 
shooting  pain,  which  remained  several  hours  in  the  lower  rectum.  From  that 
time  there  had  been  sensations  of  heat  and  fullness  about  the  rectum,  with 
now  and  then  sharp,  drawing,  and  jerking  pains.  During  the  last  two  days 
she  could  feel  lumps  at  the  side  of  the  anus  which  were  exceedingly  painful 
when  touched.  On  examination  several  cutaneous  tags  were  found,  one  of 
tliem  edematous,  red,  and  very  sensitive.  On  separating  the  anal  margins  an 
irritable  ulcer  almost  concealed  within  a  fold  of  the  inflamed  pile  was  dis- 
covered. Excision  of  the  tumors  was  at  once  advised  and  consent  secured. 
Ether-spray  was  applied  to  all  the  tumors  until  local  anesthesia  was  produced. 
Each  hemorrhoid  was  seized  in  turn  with  catch-forceps,  drawn  down,  and  cut 
off  with  curved  scissors;  the  sphincters  were  then  gradually  dilated  with 
bougies,  and  that  portion  of  the  fissure  remaining  within  the  anus  cauterized 
with  silver  nitrate.    In  one  week  the  patient  was  well. 

See  Literature  on  Hemorrhoids   (Piles),  page  471. 


CHAPTER  XXVIII 

SYMPTOMS,    DIAGNOSIS,    AND    PROGNOSIS   OF  INTERNAL 
HEMORRHOIDS  (PILES) 

SYMPTOMS 

The  clinic  manifestations  of  internal  hemorrJwids  vary 
widely  according  to  the  kind,  number,  size,  and  location  of 
the  tumors,  and  whether  they  are  highly  inflamed,  ulcerated, 
or  strangulated.  Some  persons  may  be  afflicted  with  hemor- 
rhoids for  several  years  and  suffer  but  little,  if  any,  pain  or 
inconvenience,  while  in  others  they  may  cause  the  most  intense 
suffering  almost  from  their  incipiency.  In  one  case  the  tumors 
may  be  multiple  and  large  and  bleed  but  slightly  or  not  at  all; 
in  another  there  may  be  but  one  small  pile  which  bleeds  pro- 
fusely. 

The  two  most  prominent  symptoms  of  internal  hemor- 
rhoids are  hemorrhage  and  pain,  the  latter  due  to  strangulation 
of  the  tumors  by  the  sphincter-muscle  when  they  protrude. 
Usually  one  or  both  of  these  symptoms  induce  the  patient  to 
apply  to  his  physician  for  relief. 

The  hemorrliage  from  internal  hemorrhoids  is  usually 
venous.  Some  authorities,  including  Allingham,  maintain  that 
it  is  sometimes  arterial,  but  Cripps,  Kelsey,  Quenu  and  Hart- 
mann,  and  others  are  just  as  positive  of  the  venous  character 
of  the  blood.  The  author  has  frequently  seen  blood  spurt  from 
an  ulcerated  internal  hemorrhoid,  but  its  character  was  such 
as  to  lead  him  to  believe  that  it  was  of  venous  origin.  The 
bleeding  may  be  slight  and  appear  as  streaks  upon  the  feces 
or  toilet-paper,  it  may  be  moderate  and  ooze  from  the  anus  for 
some  time  after  defecation,  or  it  may  be  so  profuse  as  to  cause 
the  patient  to  faint  from  loss  of  blood  while  at  stool.  In  such 
cases  if  the  hemorrhage  is  not  arrested  death  may  ensue.  The 
blood  may  drip  from  the  protruded  tumors  during  stool  or  after 
they  have  been  returned  above  the  sphincter;  it  may  be  dis- 
charged fresh  and  fluid,  or,  if  retained  for  some  time,  it  is 
voided  in  clots  (coffee-ground  stools),  sometimes  mixed  with 
pus  and  mucus.  When  the  hemorrhages  are  profuse  and  occur 
at  frequent  intervals  for  a  considerable  time,  the  patient  may 
(424) 


INTERNAL  HEMORRHOIDS  425 

become  anemic,  greatly  reduced  in  weight,  and  totally  incapaci- 
tated. Such  patients  are  extremely  nervous  and  despondent, 
and  it  is  almost  impossible  to  convince  them  that  they  are  not 
suffering  from  cancer  or  some  incurable  disease. 

In  older  times  the  surgeon  was  afraid  to  arrest  these  hem- 
orrhages for  fear  that  some  internal  disease,  such  as  consump- 
tion or  dropsy,  would  develop.  Happily  for  the  patient,  this 
superstition  has  almost  disappeared.  The  author  believes  that 
the  bleeding  does  not  seriously  impair  the  health  of  plethoric 
persons,  but  the  annoyance  is  so  great  and  the  nervous  phe- 
nomena so  distressing  that  even  in  these  cases  the  hemorrhages 
should  be  arrested. 

Usually  the  first  knowledge  which  the  patient  has  of  the 
existence  of  hemorrhoids  is  afforded  by  the  appearance  of  a 
small  tumor  which  protrudes  during  defecation  and  returns 
spontaneously;  afterward  the  tumor  is  again  noticed  after  stool, 
and  now  other  tumors  may  also  protrude  (Plate  XXII).  As 
the  disease  progresses  the  piles  become  larger,  come  down 
more  frequently,  and  no  longer  return  spontaneously,  but  re- 
quire to  be  replaced  after  each  stool ;  as  a  result  of  frequent 
handling  they  become  sensitive,  swollen,  inflamed,  and  ulcer- 
ated, and  the  sphincter-muscle  grows  irritable.  Later  on  one 
or  more  of  the  tumors  are  caught  in  the  grasp  of  the  sphincter- 
muscle  and  rapidly  increased  in  size.  They  are  then  difficult  to 
return,  and  when  they  are  replaced  they  act  as  foreign  bodies, 
excite  irritation,  and  are  almost  instantly  expelled,  to  be  again 
seized  by  the  muscle,  which  contracts  so  tightly  around  them 
as  to  cause  strangulation.  Unless  properly  treated,  they  soon 
become  gangrenous  and  slough  off. 

The  pain  is  comparatively  insignificant  in  the  early  stages 
of  hemorrhoids,  but  after  the  tumors  become  ulcerated  there 
is  soreness,  sensations  of  heat  and  fullness,  and  sometimes 
defecation  causes  acute  pain.  When  the  sphincter  is  irritable 
and  the  tumors  are  caught  in  its  grasp,  the  pain  is  constant 
and  agorfizing;  under  such  circumstances  it  is  impossible  for 
the  patient  to  obtain  rest  or  relief  in  any  position  until  the 
irritability  of  the  muscle  has  been  overcome  or  the  tumors 
have  sloughed  off  or  have  been  removed  by  operation. 

Other  symptoms  which  may  be  induced  by  internal  hem- 
orrhoids are  vesic  and  prostatic  disturbances,  proctitis,  and  re- 
flected pain;   when  ulceration  is  extensive,  the  discharges  may 


426  DISEASES  OF  THE  RECTUM  AND  ANUS 

induce  excoriations  of  the  ano-gluteal  region,  causing  a  per- 
sistent annoying  pruritus;  if  infection  occurs,  abscess  and 
fistula  may  follow. 

DIAGNOSIS 

The  diagnosis  of  internal  hemorrhoids  (piles)  is  not  diffi- 
cult when  a  full  history  of  the  case  is  obtained  and  a  proper  ex- 
amination made.  When  the  tumors  protrude  the  condition  is 
recognized  at  a  glance.  In  most  cases,  however,  there  is  no 
external  evidence  of  internal  piles.  It  is  necessary  therefore 
to  give  an  injection  of  warm  water  and  request  the  patient  to 
bear  down,  which  effort  causes  the  hemorrhoids  to  protrude, 
and  enables  the  examiner  to  determine  the  number  and  size  of 
the  tumors  without  resorting  to  the  speculum  or  digital  exami- 
nation. Examination  with  the  speculum,  except  when  the  tu- 
mors are  large  and  hypertrophied,  is  unsatisfactory,  because, 
when  the  instrument  is  opened,  the  parts  are  stretched  and  the 
pile  flattened  out,  thus  destroying  its  tumor-like  appearance. 
If,  however,  the  speculum  is  tilted  sharply  as  it  is  withdrawn 
the  tumors  may  be  forced  out  in  front  of  it.  Owing  to  the  pli- 
ability of  internal  hemorrhoids,  it  is  difficult  to  locate  them 
by  digital  examination  unless  they  are  thickened  or  ulcerated. 
By  everting  the  anus  the  tumors  are  brought  into  view;  this 
is  especially  easy  in  women,  in  whom  the  tumors  may  be  turned 
out  through  the  anus  by  two  fingers  inserted  into  the  vagina. 

Internal  hemorrhoids  have  been  confused  with  almost 
every  rectal  disease  which  is  accompanied  by  hemorrhage,  and 
with  every  variety  of  tumor  which  occurs  in  the  ano-rectal 
region. 

The  following  are  the  diseases  which  are  most  often  con- 
fused with  internal  piles  : — 

1.  Villous  tumors.  3.  Venereal  warts. 

2.  Malignant  growths.  4.   Pruritus  ani. 

5.   Hemorrhages. 

Villous  Tumors  are  known  by  their  broad  base,  slow  growth, 
spongy  feel,  bright  color,  and  frequent  hemorrhages. 

Malignant  Growths  in  the  early  stage  present  a  numljer  of 
hard  nodules  on  the  side  of  the  rectal  wall ;  at  a  later  date  they 
become  larger  and  break  down,  after  which  the  diagnosis  is 
made  without  difficulty. 


INTERNAL  HEMORRHOIDS 


427 


Venereal  Warts  can  be  distinguished  by  their  large  number 
and  circumscribed  location.  They  are  soft,  pedunculated, 
fragile,  bifurcated,  of  a  dark-grayish  color,  and  give  off  a  very 
disagreeable  odor. 

Pruritus  Ani  is  frequently  called  itching  piles.  There  is  no 
pathologic  reason  for  this,  since  there  is  absence  of  both  tumors 
and  hemorrhage.  The  itching  is  caused,  in  a  large  percentage 
of  cases,  by  some  irritating  discharge  from  the  rectum,  thread- 
worms, and  neuroses  or  eczema  of  the  skin. 

Hemorrhages  of  all  kinds,  coming  from  the  rectum,  are  usu- 
ally attributed  to  bleeding  piles.  In  many  such  cases  the  entire 
absence  of  piles  can  be  demonstrated;  the  bleeding  is  due  to 
ulceration,  injury,  fissure,  etc. 

Because  of  the  protrusion,  procidentia  recti  and  polyps  have 
frequently  been  mistaken  for  hemorrhoids.  The  differential 
diagnosis  of  these  affections  is  given  in  the  appended  table. 


Table  XIV.     Differential  Diagnosis  between  Hemorrhoids, 
Procidentia  Recti,  and  Polyps 


NO. 

CHARACTERISTICS. 

HEMORRHOIDS. 

PROCIDENTIA   RECTI. 

POLYPS. 

1 

Occurrence. 

Middle  life. 

Any   age;  most  frequently 
in   children. 

All  ages. 

2 

Si:^e. 

Small. 

Very   large. 

Large   or  small. 

3 

Shape. 

Ovoid. 

Pyriform. 

Bell-clapper. 

4 

Number. 

Multiple. 

Single. 

Usually  single. 

5 

Color. 

Purple. 

Red,  velvety-like. 

Color  of  the  mu- 
cous membrane. 

6 

Hemorrhage. 

Usually  profuse. 

None    except    when    ulcer- 
ated. 

Seldom. 

7 

Discharge. 

None. 

Considerable;  mucus. 

Slight ;   mucus. 

8 

Openings. 

None. 

Slit-Iike  in  center. 

None. 

9 

Attachments. 

Segmental. 

Includes  entire  circumfer- 
ence of  the   bowel. 

Pedunculated. 

10 

Protrude. 

May  or   may  not. 

Always  during  defecation. 

Rarely. 

n 

Returns  spontane- 
ously. 

Frequently. 

Rarely. 

Usually  except 
when  strangu- 
lated. 

12 

Revealed  by 

External     or     internal 
examination. 

External   examination. 

Internal    usually. 

13 

Pain. 

Extremely  painful  when 
ulcerated  or  strangu- 
lated. 

No     pain ;      sensation     of 
weight,     fvllness,      and 
dragging   down. 

Slight  pain  ;  sen- 
sation of  foreign 
body  in  rectum. 

14 

Feces  discharged. 

Between  the  tumors. 

Through   central   slit. 

Beside  the  tumor. 

15 

Tendency   to    recur 
after   operation. 

Never   recur. 

Occasionally. 

More   frequently. 

428  DISEASES  OF  THE  RECTUIM  AND  ANUS 

PROGNOSIS 

When  uncomplicated,  hemorrhoids  (piles)  rarely  end  fa- 
tally; if,  however,  they  are  permitted  to  run  an  uninterrupted 
course  or  if  improperly  treated,  they  persist  throughout  the  re- 
mainder of  the  patient's  life,  causing  much  suffering  and  annoy- 
ance and  may  completely  disable  him.  Palliative  treatment  of 
the  disease  accomplishes  little  toward  a  permanent  cure,  but 
there  is  no  other  affection  in  which  the  prognosis  is  better  than 
in  hemorrhoids,  provided  the  tumors  are  removed  by  a  radical 
operation. 

After  patients  have  recovered,  they  frequently  ask  if  a  re- 
currence will  take  place.  This  is  a  difficult  question  to  answer, 
for  there  are  many  things  to  take  into  consideration.  It  can 
be  stated  positively  that  those  piles  which  have  been  removed 
by  radical  operation  will  never  return,  but  whether  others  will 
present  themselves  depends  not  only  upon  the  operation  se- 
lected and  the  thoroughness  with  which  it  is  performed,  but 
perhaps  more  upon  tht  causes  of  the  piles.  When  they  are  a 
symptom  of  some  other  condition, — as  a  disordered  liver,  ob- 
structed circulation,  stricture,  retroverted  uterus,  etc., — re- 
lapse may  occur  in  rare  instances,  unless  the  cause  is  removed 
at  the  same  time  the  piles  are  operated  on.  When  persons  have 
been  discharged  before  ulceration  has  entirely  healed,  bleeding 
may  follow  defecation;  but  they  can  be  assured  of  ultimate  re- 
covery. From  experience  and  observation  of  patients  pre- 
viously subjected  to  any  of  the  operations  advocated  by  the 
writer,  he  can  say  that  the  recoveries  are  eminently  pleasing  in 
uncomplicated  cases,  and  that  recurrence  is  quite  the  excep- 
tion ;  in  fact,  it  was  never  found  necessary  to  operate  twice  upon 
the  same  patient. 

See    Literature  on  Hemorrhoids   (Piles),  page  471. 


CHAPTER  XXIX 

TREATMENT  OF  INTERNAL  HEMORRHOIDS 

Biblical  and  ancient  writers  record  cures  of  hemorrhoids 
through  the  agency  of  images  made  from  precious  metals  de- 
posited as  trespass  offerings  in  the  temple  and  also  through 
carrying  or  wearing  amulets  of  one  kind  or  another.  Accord- 
ing to  both  Galen  and  Paulus  Aegineta,  the  "Hieracites"  and 
"Indian"  stones,  when  worn  in  this  fashion,  were  a  sure  cure 
for  bleeding  hemorrhoids.  Strange  as  it  may  seem,  the  treat- 
ment of  various  diseases  by  amulets  still  exists.  Even  in  this 
enlightened  country  "amulets"  or  charms  are  carried  to  guard 
against  or  cure  not  only  these  diseases,  but  many  others.  The 
writer  has  met  a  number  of  persons  who  carried  amulets  and 
firmly  believed  in  their  power  to  heal  or  ward  off  disease.  In 
the  West  great  rehance  is  placed  upon  the  imagined  preventive 
and  curative  virtues  of  the  "buckeye"  (horse-chestnut,  hippo- 
castanum)  and  the  potato.  The  former  is  still  carried  as  a 
"sure  cure"  for  "piles."  To  be  effective,  the  potato  must  be 
"dug  at  midnight  in  the  dark  of  the  moon  and  carried  in  the 
left  pants'  pocket  till  slick  and  petrified";  it  is  then  looked 
upon  as  a  never-failing  cure  and  preventive  of  "sciatiky"  and 
"roomatiz."  In  commenting  upon  these  customs  Bodenhamer 
adds:  "I  would  respectfully  recommend  to  each  advocate  for 
the  employment  of  amulets  in  the  treatment  of  disease  that 
he  or  she  should  wear  the  precious  stone  chrysolite  (lapis 
chrysoliihus)  in  a  ring  on  the  middle  finger  of  the  left  hand, 
as  this  stone  is  described  as  being  the  friend  or  patron  of 
wisdom,  and  the  enemy  of  folly."  "Indiicit  sapientiam  fugat 
stultitiam." 

A  spontaneous  cure  of  hemorrhoids  rarely  takes  place. 
When  it  does  occur  it  may  be  the  result :  (a)  Of  an  ulceration 
which  destroys  the  tumor,  or  an  ulcer  which  when  healed  is 
followed  by  the  formation  of  sufficient  scar-tissue  or  inflam- 
matory deposits  to  obstruct  or  contract  upon  the  veins  and 
obliterate  the  varicose  condition,  (b)  When  internal  hemor- 
rhoids protrude  frequently  the  sphincter  may  become  irritable 
and  contract  around  them;    if  the  irritability  continues,  the 

(429) 


430  DISEASES  OF  THE  RECTUM  AND  ANUS 

muscle  tonically  contracts  about  the  protruding  piles,  which 
in  time  become  strangulated,  swollen,  and  gangrenous,  and 
finally  slough  off. 

Depending  upon  the  general  health  of  the  patient  and  the 
size,    number,    location,    condition,    and    complications    of    the 
tumors,  the  treatment  of  internal  hemorrhoids   (piles)    is: — ■ 
1.  Non-operative.  2.  Surgical. 

NON=OPERATIVE  TREATMENT 

In  diminishing  pain,  allaying  inflammation,  and  reducing 
the  size  of  the  tumors,  much  can  be  accomplished  by  the  in- 
telligent use  of  non-surgical  measures.  Little,  however,  is  to  be 
expected  from  them  in  the  way  of  a  permanent  cure,  especially 
when  the  hemorrhoids  are  large,  hypertrophied,  and  protrud- 
ing. If  the  patient  is  debilitated,  his  general  condition  should 
be  improved  by  tonics,  nourishing  diet,  and  out-door  exercise. 
Any  disease  of  the  colon,  rectum,  or  neighboring  organs  which 
induces  straining  or  congestion  of  the  rectal  veins  or  an  irri- 
tating discharge  should  be  corrected  or  removed.  It  is  neces- 
sary to  correct  any  disease  of  the  heart  or  liver  which  would 
tend  to  produce  congestion  of  the  superior  hemorrhoidal  veins. 
It  is  always  essential  to  correct,  as  far  as  possible,  the  diet  and 
prevent  constipation  in  order  to  avoid  accumulation  of  hard- 
ened feces,  which  always  aggravates  the  hemorrhoidal  condi- 
tion. If  necessary,  small  doses  of  salts,  Carabaha  water,  or 
other  suitable  cathartic  should  be  given  to  induce  one  semi- 
solid stool  daily ;  when  the  feces  are  retained  in  spite  of  these 
remedies,  they  should  be  removed  by  injections  of  soap-suds 
or  warm  water  containing  oil  or  glycerin;  but  the  enemata 
should  be  discontinued  immediately  when  a  daily  action  can  be 
had  without  them. 

When  the  hemorrhoids  are  strangulated,  ulcerated,  or 
inflamed,  the  patient  should  remain  in  bed  in  the  recumbent 
position,  and  hot  poultices,  the  ice-bag,  or  soothing  and  astrin- 
gent remedies  should  be  applied  to  the  parts.  Where  the  piles 
are  simply  inflamed  and  there  is  no  irritability  of  the  sphincter, 
cold  or  astringent  applications  give  the  best  results.  When, 
however,  the  tumors  are  strangulated  by  the  sphincter,  hot 
stupes,  poultices,  and  soothing  remedies  afford  the  most  relief, 
because  they  reduce  spasmodic  contractions  of  the  muscle  and 
allay  pain. 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


431 


The  two  most  essential  steps  in  the  non-surgical  treatment 
are  (1)  to  reduce  inflammation  of  the  hemorrhoids,  and  (2)  to 
return  the  tumors  above  the  sphincter-muscle  as  soon  as  pos- 
sible. The  author  has  always  found  the  following  simple  oint- 
ment effective  in  the  treatment  of  inflamed  hemorrhoids : — 

IJ  Morphinse  sulphatis   gr.  viij      52 

Hydrargyi  chloridi  mit gr.  xij       78 

Vaselini    gj  30 

M.     Sig. :    Apply  freely  in  the  rectum  to  the  tumors  and  about  the  anus. 


In  order  to  remove  the  discharge  and  remains  of  prior 
applications  it  is  most  essential  to  bathe  the  parts  thoroughly 
with  hot  water  before  a  fresh  application  is  made. 

Other  combinations  which  the  writer  has  found  reliable 


are 


B  Ext.   opii   3ss  2 

Cocainge  hydrochloratis gr.  x 

Menthol!    gr.  xx    1 

Ungt.  zinei  oxidi  §j  30 

M.     Sig.:    Apply  to  hemorrhoids. 

IJ  Ext.  opii, 
Ext.  arnicse, 
Ext.  belladonnge  folior.  ale aa  3j  4 

M.     Sig.:    Apply  direct  to  hemorrhoids  and  lower  rectum. 


For  hemorrhoids   complicated   by   ulceration    Allingham 


uses 


IJ  Bismuthi  subnit 3ij 

Hydrargyri  chloridi  mite   9  ij 

Morphinge  sulphatis   gr.  iij 

Glycerin! 3!j 

Ungt.  petrolat! ^j 

M.     Sig.:    Apply  with  pile-syringe. 


30 


6 
195 


As  an  application  to  the  hemorrhoids,  Ball  prefers : — • 

R  Morphinse  hydrochlor gr.  x         165 

Ext.  belladonnse, 

Acid!  tannic! aa  3j  41 

Vaselini, 

Lanolin!   aa  Bj  30| 

M.  et  ft.  unguentum. 

Sig.:    Apply  to  the  tumors  frequently. 


432  DISEASES  OF  THE  RECTUM  AND  ANUS 

Engle  uses : — 

IJ  Aristol 3ss  2 

Balsami  Peruviani   3j  4 

Ungt.  simplicis §j  30 

M.     Sig.:    Apply  to  lower  rectum  after  defecation. 

Falk  recommends  for  an  ordinary  attack  of  piles : — 

I^  Cocainse  hydrochlor., 

MorphinaB  sulphatis   aa  gr.  vj  39 

Ext.  belladonnse 3ss  2 

Liquor  plumbi  subacetatis  3ss  2 

Ungt.  stramonii 3v  20 

Ungt.  acidi  tannici giij  90 

M.     Sig.:     Apply  freely   after  the   parts   have   been   bathed  for  several 

minutes  in  warm  water.    Repeat  four  times  daily  and  after  each  stool. 

Mathews  is  partial  to  the  following  ointment : — 

IJ  Cocainre  muriatis    gr.  xij      178 

lodoformi    3j  4 

Ext.  opii    3ss  2 

Vaselini   §j  30 

M.     Sig.:    Use  through  pile-pipe  or  apply  locally. 

Lotions,  containing  alum,  arnica,  hamamelis,  lead  acetate, 
carbolic  acid,  silver  citrate  or  lactate,  boric  acid,  tannic  acid, 
iron,  chrysarobin,  krameria,  ichthyol,  glycerin,  or  like  reme- 
dies are  very  useful  to  arrest  bleeding,  reduce  inflammation, 
and  produce  astringent  action  upon  the  hemorrhoids.  Of 
these  the  author'has  obtamed  the  best  effects  from  the  lead- 
and-opium  wash,  the  formula  for  which  is  given  in  the  pre- 
ceding chapter  (page  420). 

Patients  who  suffer  from  protruding  internal  non-strangu- 
lated hemorrJioids,  which  come  down  frequently  while  they  are 
at  work,  and  who  cannot  afford  the  time  to  have  them  treated, 
should  wear  some  sort  of  a  hemorrhoidal  truss  (Fig.  138) 
to  keep  the  tumors  well  above  the  sphincter. 

The  writer's  experience  with  suppositories  in  the  treat- 
ment of  inflamed  or  protruding  hemorrhoids  has  been  unsatis- 
factory. The  ordinary  suppository  is  either  so  soft  that  the 
patient  crushes  it  in  his  efforts  to  introduce  it  or  it  is  so  hard 
that  it  acts  as  a  foreign  body  and  excites  the  sphincter  to 
renewed  contractions.  Morphine,  opium,  belladonna,  hyos- 
cyamus,  eucaine,  and  cocaine,  alone  or  in  combination  with 
some  astringent  or  antiseptic,  are  the  remedies  which  have  been 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


433 


most  frequently  used  in  the  form  of  suppositories.     For  hem- 
orrhoids with  tenesmus  Andrews  recommends : — 


165 


IJ  Pulveris  opii, 

Ext.  belladonnse    aa  gr.  x 

01.  theobrom q.  s. 

M.  et  ft.  suppositoria  No.  xv. 

Sig.:    Insert  one  when  needed  to  relieve  pain. 

Engle  uses  the  following  suppositories : — 

IJ  Aristol 3j 

Ext.  opii    gr.  iiss 

Ext.  belladonnse    gr.  Vs 

Quininse  hydrochlor gr.  xxij 

M.  et  ft.  suppositoria  No.  vj. 

Sig.:     Insert  one,  morning  and  evening,  after   previous  irrigation  with 
cold  water. 


Fig.  138. — Hemorrhoidal  Truss. 

SURGICAL  TREATMENT 

The  aid  of  surgery — sought  in  all  ages  for  the  cure  of 
piles — has  brought  much  benefit  to  this  class  of  sufferers. 
Many  of  the  operations  now  in  vogue — such  as  ligation,  cau- 
terization, crushing,  etc. — were  practiced  by  the  ancients  with 
more  or  less  success. — but  with  much  pain,  for  in  those  days 
anesthetics  were  not  known. 

In  many  cases  the  surgeon  will  not  be  consulted  until  the 
patient  has  an  acute  attack  of  piles,  and  then  he  will  not  be 
permitted  to  resort  to  operative  procedures  until  all  non-surgical 
measures  have  failed  to  give  relief.  Such  measures  at  times 
afford  much  relief  and,  in  a  few  'cases,  a  cure;  but  a  longer 
time  is  required  and  the  suffering  is  much  greater  than  if  an 
operation  had  been  performed  in  the  beginning.  This  being  the 
case,  and  no  other  complications  existing,  the  patient  should  be 


434 


DISEASES  OF  THE  RECTUM  AND  ANUS 


advised  to  undergo  at  once  the  trivial  operation  necessary  for  a 
radical  cure,  regardless  of  the  condition  of  the  piles. 

When  it  has  been  decided  that  an  operation  is  necessary, 
the  one  best  suited  to  the  case  under  consideration  should  be 
selected.  The  author  would  state  that  he  adheres  exclusively  to 
no  particular  operation,  but  always  endeavors  to  select  the  one 
best  suited  to  the  case  at  hand.     Many  operations  have  been  de- 


Fig.  139.— Clover's  Crutch. 

vised  for  the  removal  or  cure  of  internal  hemorrhoids  (piles).  In 
this  chapter,  however,  a  detailed  description  of  only  those  oper- 
ations which  have  been  most  widely  practiced  will  be  given. 
The  Preparation  of  the  Patient  for  Operation  is  an  important 
part  of  the  surgical  treatment.  The  general  health  should 
be  carefully  looked  into,  and,  if  found  below  par,  it  must 
be  corrected  as  far  as  possible.  The  urine  should  be  ex- 
amined to  detect  the  presence  of  any  kidney  or  bladder  com- 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


435 


plication.  If  the  patient  is  suffering  from  malaria,  a  few  doses 
of  quinine  is  beneficial.  It  is  unsafe  to  operate  for  hemor- 
rhoids upon  persons  in  the  last  stages  of  phthisis,  Bright's 
disease,  diabetes,  or  organic  heart  disease,  especially  where  a 
general  anesthetic  is  necessary. 

On  the  morning  of  the  day  preceding  the  operation  a 
Hberal  dose  of  some  reliable  cathartic — such  as  salts,  licorice- 
powder,  calomel,  Carabaiia,  or  Hunyadi  water — should  be 
given  to  clear  the  intestine.  Three  hours  previous  to  the  op- 
eration the  bowel  should  be  flushed  with  a  copious  high  soap- 
suds injection,  and  this  should  be  followed,  one  hour  before 


Fig.  140.— Dilatation  of  the  Sphincter  Ani. 

the  operation,  by  a  small  enema  of  warm  water  and  suf- 
ficient glycerin  to  excite  slight  tenesmus.  This  enema  should 
never  consist  of  more  than  1  pint  (500  cubic  centimeters),  be- 
cause if  a  larger  amount  is  used  a  part  of  it  will  remain  in  the 
colon  and  may  subsequently  flow  down  over  and  soil  the 
field  of  operation.  The  external  parts  should  be  thoroughly 
cleansed,  and,  if  necessary,  shaved;  but,  unless  the  wound  is 
to  be  sutured,  the  writer  omits  the  shaving,  because  of  the 
discomfort  caused  the  patient  during  the  period  when  the  hairs 
are  growing  out.  When  a  general  anesthetic  is  to  be  given, 
no  food  should  be  taken  for  several  hours  previous. 


436 


DISEASES  OF  THE  RECTUM  AND  ANUS 


The  following  are  the  operations  which  have  been  sug- 
gested for  the  relief  of  internal  hemorrhoids^ : — 

1.  Clamp  and  cautery. 

2.  Ligature. 

3.  Excision. 

4.  Injection  of  caustic  and  astringent  solutions. 

5.  Submucous  ligation. 

6.  Cauterization :    (1)  by  puncture,  (2)  linear,  and  (3)  by 
galvanocautery-wire. 

7.  Divulsion. 

8.  Crushing. 

9.  By  the  ecraseur. 

10.  Application  of  chemic  caustics. 

The    Clamp-and-Cautery    Operation    was    originated    by    Mr. 
Cusack,  of  Dublin.     It  was  introduced  into  London  by  Mr. 


Gant's  Hemorrhoidal  and  Tissue  Forceps. 


Henry  Lee,  and  later  was  brought  prominently  before  the 
profession  in  England  by  Mr.  Henry  Smith,  while  delivering 
lectures  before  the  Medical  Society  of  London,  during  the 
winter  of  1864  and  1865.  He  had  previously  performed  the 
operation  many  times.  Up  to  the  date  of  the  origin  of  this 
operation  the  ligature  was  used  universally  throughout  Great 
Britain.  Through  the  instrumentality  of  Mr.  Smith  many  sur- 
geons were  induced  to  use  the  clamp  and  cautery,  and  the 
majority  who  gave  it  a  fair  test  were  much  pleased  with  the 
results.  It  is  popular  in  Germany ;  but  in  America  it  is  a  ques- 
tion which  is  the  more  popular,  the  clamp  and  cautery  or  the 
ligature,  both  having  many  advocates  of  equal  ability.  The 
writer  is  partial  to  the  clamp-and-cautery  operation.  By  the 
aid  of  the  modern  clamps  and  the  Paquelin  cautery  or  cautery- 
irons  (Figs.  144,  148,  and  149),  the  operation  is  not  difficult  and 
can  be  performed  with  rapidity.     If  ordinary  care  is  observed,  it 

'  See,  Local  Anesthesia,  Chapter  XLI. 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


437 


is  not  a  barbarous  procedure,  as  is  often  claimed  by  its  opponents, 
but  a  scientific  surgical  operation,  whereby  only  the  diseased 
tissue  is  removed.  The  pain  which  follows  the  clamp-and-cau- 
tery  operation  is  less  than  that  of  any  other  operation  for  piles. 

The  technic  of  the  clamp-and-caiitery  operation  as  performed 
under  general  anesthesia  by  the  author,  is  as  follows : — 

First  Step. — The  patient,  having  been  previously  prepared 
and  anesthetized,  is  placed  in  the  lithotomy  position,  the  limbs 
well  flexed  and  held  by  an  assistant  or  by  means  of  a  Clover 
crutch  (Fig.  139).     The  sphincter  is  gradually  and  thoroughly 


Fig.  142.— Severing  the  Mucous  Membrane  from  the  Skin. 

divulsed  by  making  pressure  with  the  thumbs  or  fingers  first 
in  one  direction  and  then  in  another  (Fig.  140).  The  hemor- 
rhoids are  then  exposed  by  everting  the  anus,  and  their 
number,  size,  and  location  noted. 

Second  Step. — Each  tumor  is,  in  turn,  firmly  grasped  with 
the  author's  hemorrhoidal  forceps  (Fig.  141)  and  tension 
made  while  the  skin  and  mucous  membrane  are  incised  at  the 
muco-cutaneous  junction.  The  pile  is  then  dissected  from  its 
submucous  attachments  (Fig.  142). 

Third  Step. — The  author's  pile-clamp  (Fig.  143)  is  now 
adjusted  in  the  groove  made  by  the  incision,  and  about  the 


438 


DISEASES  OF  THE  RECTUM  AND  ANUS 


pedicle  of  the  partly-detached  pile.  The  screw  should  be  well 
tightened,  but  not  run  down  too  far,  as  the  clamp  may  be 
sprung. 

Fourth  Step. — The  clamp  holding  the  tumor  is  grasped  in 
the  left  hand  while  that  portion  of  the  pile  external  to  it 
is  cut  off  by  scissors  carried  up  from  below,  as  shown  in  Plate 
XXVI.    The  stump  should  be  curetted  to  remove  any  clot  and 


Fig.  143.— Gant's  Pile,  Prolapse,  and  Polyp  Clamp.  The  Small  Figures  Show 
the  Different  Clamps  and  their  Clamping  Power:  A,  Gant's;  B,  Kelsey's; 
C,  Smith's;  D,  Langenbeck's. 


to  expose  the  edges  of  the  wound,  which  sometimes  turn  in 
as  they  are  cut. 

Fifth  Step. — Every  part  of  the  stump  is  now  thoroughly 
burned  with  the  flat  point  of  the  Paquelin  cautery  (Fig. 
144),  care  being  taken  that  no  vessels  are  left  uncauterized 
between  the  edges  of  the  wound  (Fig.  145).  The  clamp  is 
then  loosened  slowly,  and,  if  any  uncauterized  bleeding-points 
are  observed,  it  should  be  readjusted  and  the  cautery  applied 
to  them;  then  the  clamp  is  again  loosened  and  removed. 
When  the  piles  are  small  or  situated  too  high  to  be  drawn 


PLATE   XXVI.—GANT'S  CLAMP  ADJUSTED    AND    SCISSORS 

IN  POSITION  FOB  EXCISION  OF  PROTRUDING 

INTERNAL  HEMORRHOIDS. 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


439 


down  and  clamped,  the  narrow  cautery-blade  should  be  drawn 
once  or  twice  across  each  pile ;  this  will  cause  them  to  shrink. 
The  cautery  may  be  applied,  if  used  with  discretion,  to  any 
dilated  veins  present  which  might  at  some  future  time  form 
piles.  If  any  external  hemorrhoids  are  present  they  should 
be  snipped  ofif,  or,  if  thrombotic,  incised  and  the  clot  turned 
out. 

Sixth  Step. — The  cauterized  stumps  are  then  gently  re- 
turned within  the  sphincter  and  held  in  by  a  Urm,  wedge-shaped 
gauze  compress  applied  over  the  anus  and  firmly  secured  in 
place  by  the  author's  operating  harness  (Fig.  146)  or  a  well 
adjusted  T-bandage.    The  patient  is  then  placed  in  bed. 


Fig.  144. — Improved  Paquelin  Cautery. 


It  is  rarely  necessary  to  tie  bleeding  vessels  which  have 
been  divided  by  the  muco-ctttaneous  incision,  as  the  vessels  are 
small  and  the  bleeding  is  arrested  by  the  compress.  The  author 
would  strongly  emphasize  the  necessity  of  thoroughly  cauterizing 
the  stumps,  because  dangerous  hemorrhage  is  most  likely  to 
follow  if  the  cautery  is  but  superficially  applied.  When  it  is 
necessary  to  use  a  sponge  it  should  be  applied  with  gentle  and 
direct  pressure  against  the  bleeding  surface,  and  never  wiped 
from  side  to  side ;  otherwise  the  cauterized  wound  will  be  torn 
open  and  hemorrhage  may  follow.  For  the  same  reason  the 
rectum  should  not  be  irrigated  nor  any  instrument  introduced 
after  the  operation  has  been  completed.  The  object  of  making 
the  muco-cutaneous  incision  is  to  allow  the  skin  to  retract  and 
to  exclude  it  from  the  cauterization.  If  the  cauterization  is 
confined  to  the  mucosa  exclusively,  as  it  should  be,,  and  if  no 


440 


DISEASES  OF  THE  RECTUM  AND  ANUS 


dressing,  packing,  or  tubes  of  any  kind  are  placed  in  the  rectum, 
there  will  be  comparatively  little,  if  any,  after-pain  and  no 
appreciable  contraction  following  the  operation;  on  the  other 
hand,  if  the  operator,  through  ignorance  or  carelessness,  burns 
the  skin  about  the  anus,  the  after-pain  will  be  most  intense,  and 
stricture  may  follow  healing  of  the  wounds.  The  author 
saves  his  patients  much  suffering  by  not  plugging  the  bowel 
with  dressing,  as  is  usually  done ;  he  has  found  that  such  a  pro- 
cedure is  unnecessary,  causes  increasing  pain  by  exerting 
pressure  upon  the  ulcers,  excites  the  levator  ani  to  frequent 


Fig.  145.— Cauterizing  the  Stump. 


contraction,  and  causes  great  pain  when  removed,  owing  to 
entanglement  of  the  granulations  in  the  meshes  of  the  gauze. 
The  author  has  performed  the  clamp-and-cautery  opera- 
tion hundreds  of  times  and  has  never  lost  a  patient  from  hem- 
orrhage, nor  has  he  seen  a  case  of  stricture  produced  by  it. 
He  has,  in  a  few  instances,  known  a  profuse  hemorrhage  to 
follow  the  operation  where  some  bleeding-point  was  not  cau- 
terized, and  he  has  also  seen  the  same  accident  follow  the  liga- 
ture operation  where  the  knot  was  improperly  tied  or  the  ends 
cut  too  short. 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


441 


In  the  author's  opinion,  when  general  anesthesia  is  employed, 
the  clamp-and-cautery  operation  should  take  precedence  over  the 
ligature  method  because  it  (a)  is  equally  as  radical,  (h)  can  be 
performed  as  easily  and  quickly,  (c)  is  no  more  likely  to  be  fol- 
lowed by  hemorrhage  or  stricture,  (d)  vesical  disturbances  are 
less  frequent,  (e)  after-pain  is  not  so  great,  and  (f)  recovery  is 
more  rapid.  When  a  ligature  has  been  applied,  it  will  not  ordi- 
narily slough  out  before  the  sixth  day,  and  then  it  leaves  an  ulcer 
which  requires  some  time  to  heal;    as  a  rule,  the  patient  is  not 


Fig.  146. — Showing  Gant's  Operating  Harness  (Back  and  Front  Views)  for  Holding 
the  Dressing  in  Place  and  Making  Firm  Pressure  Over  the  Anus  After  Eectal 
Operation  to  Prevent  Bleeding. 

able  to  be  out  before  the  seventh,  and  sometimes  not  before  the 
tenth  day/  After  the  clamp-and-cautery  operation  the  ulcers  are 
usually  sufficiently  healed  on  the  third  or  fourth  day  to  permit 
the  patient  to  sit  up;  at  the  end  of  a  week  he  is  able  to  return 
to  business.  After  either  operation  the  patient  may  be  unable 
to  void  his  urine,  but  this  complication  is  more  frequent  after 
the  ligature  operation.  The  author  has  never  known  infection 
to  occur  from  either  of  these  operations,  but  he  has  seen  it  in 
cases  where  the  pile-tumors  were  excised  and  the  wound  closed 
with  catsrut  or  other  sutures. 


'  This  is  true  of  the  ordinary  hospital  ease  where  a  thick  silk  ligature  is  employed,  but  the 
author  has  recently  adopted  the  use  of  a  linen  ligature  which  cuts  out  in  a  few  days  and 
materially  shortens  convalescence. 


443  DISEASES  OF  THE  RECTUM  AND  ANUS 

In  this  connection  the  author  wishes  to  describe  his  pile- 
damp  (Plate  XXVI  and  Fig.  143),  which  he.  has  used 
to  the  exclusion  of  all  others  for  some  years  past.  It 
has  done  such  admirable  work  that  he  feels  justified  in 
commending  it  to  the  profession.  Most  pile-clamps  now 
on  the  market  are  unsatisfactory  for  the  reason  that  they  do 
not  exert  equal  pressure  along  the  entire  length  of  the  blades ; 
and,  as  a  result  of  this  imperfection,  the  writer  came  near  losing 
two  patients  from  hemorrhage.  Other  clamps — such  as  Kel- 
sey's.  Smith's  (Fig.  147),  Langenbeck's,  etc. — are  made  like  a 
pair  of  scissors,  having  a  rivet  near  the  heel  of  the  blade,  and 
when  the  tumor  is  grasped  the  part  nearest  the  heel  of  the 
clamp  is  held  tightly  and  that  near  the  tip  loosely  or  not  at  all 
(Fig.  143,  B,  C,  and  D).  Consequently,  when  that  portion  of 
the  tumor  external  to  the  clamp  is  cut  off,  all  of  the  tissues 


Fig.  147. — Smith's  Hemorrhoidal  Clamp. 

except  those  nearest  the  heel  slip  through  the  clamp  before  the 
operator  has  a  chance  to  cauterize  them,  thus  subjecting  the 
patient  to  the  danger  of  a  serious,  if  not  a  fatal,  hemorrhage. 
The  author's  clamp  differs  materially  from  the  others  (Fig. 
143).  It  is  so  constructed  that  the  blades  are  at  right  angles 
to  the  handle  which  insures  their  remaining  parallel  and  dis- 
tributing equal  pressure  at  every  point  (Fig.  145),  no  matter 
how  far  they  may  be  apart ;  not  even  the  slightest  portion  of 
the  tumor  can  slip  through  and  escape  cauterization.  This 
renders  a  hemorrhage  after  the  clamp-and-cautery  operation, 
when  properly  performed,  an  improbable,  if  not  impossible, 
occurrence.  The  following  are  some  of  the  good  points 
claimed  for  this  clamp : — 

1.  It  is  neat  and  attractive. 

2.  It  is  aseptic. 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


443 


3.  It  is  strong,  and  does  not  spring  or  get  out  of  order. 

4.  It  can  be  adjusted  quickly  and  with  perfect  ease. 

5.  It  does  not  obstruct  the  operator's  view. 

6.  It  has  a  strong  spring  which  separates  the  blades,  and 
a  screw  with  a  double  thread ;  a  tap  on  the  nut  is  sufficient  to 
run  it  from  top  to  bottom. 

7.  When  operating  high  up  in  the  bowel  it  not  only  does 
the  work  of  a  clamp,  but  that  of  a  speculum  as  well. 

8.  It  can  be  used  as  well  with  the  patient  in  one  position 
as  in  another. 

9.  It  is  as  well  suited  for  the  removal  of  piles  high  up  as 
when  they  are  protruded. 


Fig.   148.— Cautery  Blow-pipe  for  Heating  Irons. 


10.  It  is  admirably  adapted  for  the  removal  of  rectal 
polyps. 

11.  It  can  be  used  for  the  removal  of  polypoid  growths  in 
the  vagina. 

12.  It  can  be  used  for  clamping  in  the  removal  of  sections 
of  the  mucous  membrane  in  cases  of  procidentia  recti  when 
the  wound  is  cauterized  or  sutured. 

13.  It  makes  an  admirable  colostomy-clamp.  It  causes  the 
segment  of  gut  to  slough  ofif  in  three  or  four  days  with  little 
pain  and  no  bleeding. 

14.  When  it  is  desirable  to  crush  piles,  it  can  be  substi- 
tuted for  the  pile-crushers  now  in  use. 

15.  It  is  a  serviceable  clamp,  for  the  reason  that  it  exerts 
equal  pressure  at  all  points  under  all  conditions. 

Martin  claims  that  by  means  of  his  damp  hemorrhoids  can 


444 


DISEASES  OF  THE  RECTUM  AND  ANUS 


be  removed  by  the  clamp-and-cautery  method  painlessly  and 
without  a  general  anesthetic;  also  that  the  patient  need  not 
remain  in-doors  more  than  three  or  four  days.  He  describes 
the  instrument  and  operation  as  follows : — 

"The  instrument  consists  of  a  hollow  cone  three  and  a 
quarter  inches  (8.35  centimeters)  in  length  and  three-fourths 
of  an  inch  (1.90  centimeters)  in  diameter  at  its  distal  extrem- 
ity, and  one  and  three-fourths  inches  (4.44  centimeters)  in 
diameter  at  its  proximal  end.  One  quadrant  of  the  cone  is 
fenestrated,  and  this  is  occupied  by  a  movable  blade  with  a 
serrated  edge,  which  contacts  with  the  serrated  cone-edge. 
The  movable  blade  is  sheathed  in  the  cone  when  the  jaws  of 
the  clamp  are  separated.  The  technic  of  the  operation  involves 
the  following  several  steps: — 


^^^^^^^^^^^^^^^^^^^ 


Fig.  149. — Cautery  Irons  Suitable  for  the  Clamp-and-Cautery  Operation. 


"1.  Hypodermic  injection  of  about  10  minims  of  ^/lo-of- 
1-per-cent.  solution  of  cocaine  into  the  ectal  and  ental  sphinc- 
ters to  secure  their  painless  dilatation.  2.  Introduction  into 
the  anus  of  the  closed  clamp  with  the  blade  directed  toward 
or  against  the  tumor.  3.  Separation  of  the  clamp's  jaws.  4. 
Hypodermic  injection  of  the  cocaine  solution  (a)  into  the 
membrane  covering  the  now  accessible  tumor-base,  and  (b) 
into  the  connective  tissue  composing  the  tumor.  5.  Clamping 
the  pile.  6.  Cutting  away  the  pile.  7.  Intermittent  applica- 
tions of  Paquelin's  cautery  to  the  pedicle.  8.  (a)  Releasing 
the  pedicle  and  fb)  withdrawal  of  the  clamp. 

"Because  of  its  peculiar  form  the  clamp  effectually  blocks 
the  field  of  operation  against  the  accidental  invasion  of  the 
feces  or  other  intestinal  detritus.  Three-fourths  of  the  quan- 
tity of  the  cocaine  solution  used  is  recovered  with  the  removal 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


445 


of  the  tumor;  hence  the  amount  of  cocaine  which  may  enter 
into  the  patient's  circulation  is  infinitesimal  and  inappreciable." 
The  Ligature  Operation  has  stood  the  test  of  time  since  hun- 
dreds of  years  before  the  nativity  of  Christ.  It  comes  down 
to  us  recommended  by  such  of  the  ancients  as  Hippocrates, 
Celsus,  and  Rhazes  the  noted  Arabic  physician  of  the  tenth 
century,  and  many  others.  The  majority  of  authors  in  later 
years,  and  up  to  the  present  day,  commend  it  as  being  one  of 


Fig.  150. — Mathews's  Pile-forceps. 


the  best  operation  for  the  cure  of  hemorrhoids.  For  instance, 
it  is  indorsed  by  Sir  Astley  Cooper,  Burke,  Cripps,  Van  Buren, 
Bodenhamer,  Syme,  Allingham,  Mathews,  and  others.  There 
is  no  question  as  to  the  pre-eminence  of  this  operation  for 
ordinary  cases  of  piles,  with  one  exception,  namely :  the  clamp 
and  cautery.  The  results  which  have  followed  these  two  opera- 
tions have  proven  that  both  are  deserving  of  the  highest  praise 
and  consideration.  The  reader  may  choose  the  one  he  can 
perform  with  the  most  satisfactory  results,  with  the  assurance 
that  a  radical  cure  will  be  effected. 


Fig.  151. — Thomas's  Curved  Tissue-forceps. 


The  ligature  operation,  as  performed  by  the  ancients,  re- 
sembles, in  many  respects,  the  operation  as  done  to-day.  Galen 
recommended  the  excision  of  that  portion  of  the  pile  external 
to  the  ligature.  Others  simply  placed  a  ligature  around  the  pile 
and  let  it  slough  off,  while  some  transfixed  the  center  of  the 
tumor  with  a  double  ligature  and  tied  it  on  both  sides.  The 
surgeons  of  to-day  differ  as  to  the  best  method  of  applying  the 
ligature.     The  majority,  however,  prefer  the  operation  which 


446  DISEASES  OF  THE  EECTUM  AND  ANUS 

was  devised  by  the  late  Mr.  Salmon  and  popularized  by  Ailing- 
ham,  Sr.,  in  St.  Mark's  Hospital,  London,  where  it  has  been 
practiced  for  the  last  fifty  years.  This  procedure  differs  from 
Galen's  method  only  in  so  far  as  to  exclude  the  nerves  from 
the  ligature  and  lessen  the  after-pain,  which  is  done  by  severing 
the  skin  and  mucous  membrane  at  the  muco-cutaneous  junc- 
tion and  applying  the  ligature  in  the  sulcus  thus  made. 

The  technic  of  the  operation  as  performed  under  general 
anesthesia  by  the  author  is  as  follows^  :— 

The  patient,  having  been  previously  prepared,  is  anesthe- 
tized and  placed  in  the  lithotomy  position,  the  limbs  well  flexed 
and  held  by  a  Clover  crutch.  The  sphincter  is  then  divulsed 
(Fig.  140)  and  the  hemorrhoids  turned  out.  Each  tumor  in 
turn  is  seized  with  the  author's  or  other  hemorrhoidal  forceps 
(Figs.  141,  150,  and  151),  drawn  down,  and  skin  and  mucous 
membrane  severed  at  the  muco-cutaneous  junction  (Fig.  142)  ; 
the  pile  is  then  dissected  up  from  its  submucous  attachments, 
and  a  strong  silk  ligature  thrown  around  its  pedicle  and  tied 
tightly  as  close  to  the  rectal  wall  as  possible  (Fig.  152)  ;  the 
portion  of  the  pile  now  external  to  the  ligature  is  excised.  After 
all  the  tumors  have  been  ligated  and  removed,  the  stumps  are 
returned  above  the  sphincter.  A  firm,  wedge-shaped  compress 
is  placed  over  the  anus,  secured  by  a  well-adjusted  T-bandage, 
and  the  patient  placed  in  bed.  When  the  tumors  are  very  large, 
they  should  be  transfixed  through  the  center  near  the  base, 
with  a  needle  carrying  a  double  ligature,  half  of  which  is  to 
be  tied  on  either  jide.  In  performing  the  ligature  operation  it 
is  most  important  to  tie  the  ligatures  very  securely,  and  not  to 
cut  the  ends  too  short,  to  avoid  their  slipping  and  causing  hem- 
orrhage. It  is  also  necessary  to  remove  any  hypertrophied  tags 
of  skin.  The  hemorrhage  from  the  muco-cutaneous  incision  is 
slight,  because  the  vessels  severed  are  small  and  the  bleeding  is 
arrested  by  the  compress. 

These  patients  may  suffer  considerably  during  the  first 
twenty-four  hours.  The  pain  during  the  three  or  four  days  fol- 
lowing the  operation  is  sometimes  quite  annoying,  though  in 
exceptional  cases  it  is  nil.  There  are  sensations  of  heat  and  full- 
ness about  the  anal  canal,  and  patients  are  frequently  awakened 
by  sudden  twitchings  at  the  anus  caused  by  spasmodic  contrac- 
tions of  the  levator  ani,  induced  by  the  presence  of  the  ligated 
stumps,  which  act  as  foreign  bodies. 

'For  ligature  operation  under  local  anesthesia,  see  Chapter  Xbl, 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


447 


Ordinarily  the  ligatures  will  cause  the  stumps  to  slough  off 
in  from  Hve  to  seven  days.  When  the  pile  is  large  and  hyper- 
trophied,  however,  a  ligature  will  occasionally  fail  to  cut  its 
way  entirely  through,  and  the  stump  is  left  hanging  by  a  sort 
of  pedicle,  and  must  be  snipped  off  with  scissors.  The  author 
is  inclined  to  think  that  this  complication  occurs  more  frequently 
than  the  friends  of  the  ligature  would  imply,  and  in  such  cases 
increased  pain  and  delayed  healing  are  always  noticeable.  The 
author  does  not  place  any  dressing  in  the  rectum  after  this  oper- 


Fig.  152.— Correct  Method  of  Ligating  Protruding  Internal  Hemorrhoids. 

ation.  As  a  rule,  patients  operated  on  by  the  ligature  are  able 
to  be  out  at  the  end  of  the  first  week,  although  the  ulceration  may 
not  be  entirely  healed. 

In  St.  Mark's  Hospital,  London,  the  death-rate  from  all 
cases  of  internal  hemorrhoids  operated  upon  by  ligature  dur- 
ing more  than  fifty  years  has  been  about  one  in  a  thousand. 
This  is  a  fine  showing,  considering  that  they  were  all  hospital 
patients.  Four  died  of  tetanus  during  March  and  April,  1858, 
but  none  has  died  from  this  cause  since.  This  would  indicate 
that  there  was  an  epidemic  of  tetanus  during  that  time. 


448  DISEASES  OF  THE  RECTUM  AND  ANUS 

The  fact  that  so  many  operators  have  obtained  the  best 
of  results  from  this  operation,  and  that  when  it  is  successful  a 
permanent  cure  is  effected,  have  won  for  it  a  very  enviable 
reputation.  The  author  believes  that  this  operation  is  a  very 
good  one,  and  its  results  are  as  satisfactory  as  those  obtained 
from  any  operation  yet  devised;  but  he  does  not  think  that 
it  deserves  precedence  over  the  clamp-and-cautery  operation, 
because  the  latter  is  followed  by  equally  as  good  results,  the 
patients  suffer  less,  and  convalescence  is  more  rapid. 

Excision  of  hemorrhoids  may  be  accomplished  either  by 
removing  the  tumors  singly  or  by  excising  the  mucous  mem- 
brane of  the  entire  circumference  of  the  lower  rectum.  Many 
operations  of  this  kind  have  been  devised,  but  none  of  them 
has  attracted  so  much  attention  as  that  originated  by  White- 
head. No  form  of  excision  has  come  into  general  favor  because 
of  the  danger  of  infection  and  the  complications  and  sequels 
which  sometimes  follow. 

The  simplest,  quickest,  and  best  method  of  excising  pile- 
tumors,  the  originator  of  which  is  not  known  to  the  author,  is 
as  follows :  Each  tumor  in  turn  is  seized  with  forceps  and  re- 
moved by  making  with  scissors  or  knife  two  semicircular  in- 
cisions around  its  base ;  bleeding  vessels  are  ligated  with  cat- 
gut, the  rectum  is  irrigated,  and  the  wound  closed  with  either 
interrupted  or  continuous  catgut  sutures.  If  the  operator 
chooses,  after  tying  the  vessels  he  may  leave  the  wound  open  to 
heal  by  granulation. 

Wright  clamps  the  pile  near  its  base  with  pressure-forceps, 
and  encircles  the  tumor  internal  to  the  clamp  with  a  continuous 
purse-string  suture,  which  he  ties  after  excising  the  external 
portion  of  the  pile  and  removing  the  forceps. 

Sims  divulses  the  sphincter,  draws  the  pile  downward, 
encircles  its  base  with  an  incision  through  the  mucosa,  ties  a 
silk  ligature  in  this  cut  (thus  including  only  the  blood-vessels 
and  connective  tissue),  excises  the  pile  external  to  the  ligature, 
and  unites  the  cut  edges  of  the  mucosa  over  the  stump  with  a 
continuous  catgut  suture. 

Jones  clamps  the  hemorrhoid,  excises  it  an  eighth  of  an 
inch  (32  millimeters)  external  to  the  clamp,  and  unites  the 
edges  of  the  wound  with  continuous  catgut  suture  before  the 
clamp  is  removed. 

Eliot  has  devised  a  special  clamp  for  excising  hemorrhoids. 


TREATMENT  OF  INTERNAL  HEMORRHOIDS        449 

It  has  holes  in  the  blades,  through  which  the  sutures  are  passed 
when  the  tumor  is  excised,  the  clamp  removed,  and  the  sutures 
tied. 

The  Whitehead  Operation  (Circular  Excision)  was  first  de- 
scribed by  Mr.  Walter  Whitehead,  of  Manchester,  England, 
in  1882,  and  in  the  British  Medical  Journal  of  February  26,  1887. 
After  criticising  such  tried  and  successful  methods  as  the  clamp- 
and-cautery  and  ligature  operations,  he  reported  the  successful 
treatment  of  three  hundred  consecutive  cases  of  hemorrhoids 
by  his  operation,  without  a  single  death,  secondary  hemor- 
rhage, abscess,  ulceration,  stricture,  or  incontinence.  This 
operation  is  based  upon  Mr.  Whitehead's  opinion  that  hemor- 
rhoids are  not  to  be  regarded  as  individual  tumors,  but  as  a 
part  of  a  diseased  condition  of  the  general  plexus  of  veins 
associated  with  the  superior  hemorrhoidal,  and  that  each  rad- 
icle of  these  veins  becomes  similarly  and  equally  affected  from 
the  initial  cause,  be  it  constitutional  or  mechanic.  He  be- 
lieves, therefore,  that  all  these  vessels  should  be  exposed  and 
the  entire  pile-hearing  area  amputated. 

The  Whitehead  operation  has  not  become  popular  in 
either  England  or  America  because  of  its  difficulty,  the  pain 
associated  with  it,  and  the  many  complications  and  unpleasant 
sequels  which  may  accompany  or  follow  it.  For  the  same 
reasons,  the  so-called  "American  Operation"  of  which  Pratt, 
of  Chicago,  is  the  champion,  has  been  practically  discarded. 
This  operation  is  not  deserving  of  special  consideration  and 
name,  for  the  reason  that  its  technic  is  practically  the  same  as 
that  of  Whitehead's,  with  the  exception  that  the  dissections  are 
begun  from  above. 

The  author  has  performed  the  Whitehead  operation  many 
times.  While  in  some  instances  the  results  were  ideal  and  the 
patients  discharged  cured  at  the  end  of  two  or  three  weeks,  in 
others  convalescence  was  prolonged  and  painful.  Indeed,  in 
not  a  few  cases  the  complications  and  sequels  which  followed 
rendered  the  patients  permanent  invalids.  Moreover,  the 
writer  has  treated  a  large  number  of  patients  suffering  from 
incontinence,  stricture,  ulceration,  proctitis,  or  pruritus,  which 
were  the  result  of  Whitehead  operations.  It  was  found  impos- 
sible to  improve  the  condition  of  most  of  these  patients,  be- 
cause either  the  sphincter-muscle  had  been  stripped  off  by  the 
operator  causing  incontinence,  or  non-union  and  retraction  of 

29 


450  DISEASES  OF  THE  RECTUM  AND  ANUS 

the  gut  had  taken  place,  leaving-  an  extensive  circular  band  of 
ulceration  which  was  difficult  to  heal.  When  healing  was 
secured  a  sufficient  amount  of  scar-tissue  was  left  to  produce  a 
tight  stricture,  extremely  difficult  or  impossible  to  reheve. 

The  technic  of  the  operation  of  excision  in  Mr.  Whitehead's 
own  words  is  as  follows : — 

"By  the  aid  of  scissors  and  a  pair  of  dissecting  forceps 
the  mucous  membrane  is  divided  at  its  junction  with  the  skin 
around  the  entire  circumference  of  the  bowel,  every  irregu- 
larity of  the  skin  being  carefully  followed.  The  external  and 
internal  sphincters  are  then  exposed  by  rapid  dissection  of  the 
mucous  membrane  and  attached  hemorrhoids.  Thus  sepa- 
rated from  the  mucous  bed  upon  which  they  rested,  they  are 
pulled  bodily  down,  any  undivided  points  of  resistance  being 
snipped  and  the  hemorrhoids  brought  below  the  margin  of 
the  skin.  The  mucous  membrane  above  the  hemorrhoids  is 
now  divided  transversely  in  successive  stages,  and  the  free 
margin  of  the  severed  membrane  above  is  attached,  as  soon 
as  divided,  to  the  free  margin  below  by  a  suitable  number  of 
silk  sutures,  after  the  hemorrhage  has  been  arrested  by  tor- 
sion." The  sutures  are  allowed  to  cut  their  way  out  or  become 
encysted. 

Mr.  Whitehead  claims  the  following  advantages  for  his 
operation : — 

1.  That  it  is  the  most  natural  method,  and  is  in  perfect 
harmony  with  surgery. 

2.  Excision,  in  addition  to  its  simplicity,  requires  no  in- 
strument not  found  in  an  ordinary  pocket-case. 

3.  It  is  a  radical  cure.  It  removes  the  peculiar  pile-bear- 
ing area. 

4.  It  is  not  more  dangerous  than  other  methods  recom- 
mended for  the  removal  of  piles. 

5.  Pain  is  less  severe  than  that  following  any  other  opera- 
tion. 

6.  The  loss  of  blood  during  the  operation  probably  ex- 
ceeds that  of  the  ligature  or  clamp  and  cautery,  but  the  dangers 
of  secondary  hemorrhage  are  unquestionably  less. 

The  author  will  discuss  these  claims  in  rotation : — 
1.  Whitehead's  excision  is  not  more  natural,  nor  is  it  more 
in  harmony  with  surgery,  than  are  other  hemorrhoidal  oper- 
ations. 


TREATMENT  OF  INTERNAL  HEMORRHOIDS  45 1 

2.  Instead  of  being  a  simple  operation,  it  requires  a  longer 
time,  more  ingenuity  on  the  part  of  the  surgeon,  and  the  best 
instruments. 

3.  Granting  it  is  radical,  just  as  good  results  can  be  ob- 
tained quicker,  with  less  pain  and  fewer  complications,  by  less 
difficult  operations. 

4.  It  is  equally,  if  not  more,  dangerous  than  the  clamp  and 
cautery  or  ligature,  and  is  certainly  more  often  accompanied 
by  complications. 

5.  Pain  after  this  operation  is  never  less,  but  usually  more, 
intense  than  after  other  radical  operations  for  piles. 

6.  Bleeding  is  profuse  during  this  operation,  and  the  dan- 
ger of  secondary  hemorrhage  is  not  lessened  by  it. 

Mr.  Whitehead's  operation  is  original,  and  will  always 
hold  a  prominent  place  in  surgery  of  the  bowel.  It  is  not,  how- 
ever, a  suitable  one  for  ordinary  or  bad  cases  of  piles,  for  two 
reasons: — 

First. — Piles  can  be  permanently  cured  by  less  difficult 
operations. 

Second. — It  is  accompanied  and  followed  by  many  com- 
plications and  sequels. 

In  the  author's  opinion,  this  operation  is  not  suitable  in 
ordinary  or  even  very  had  cases  of  hemorrhoids.  While  he  be- 
lieves it  should  have  a  place  in  surgery,  it  does  not  deserve  the 
prominent  position  its  originator  would  have  it  occupy. 

It  has  been  the  custom  of  the  author  to  perform  this  op- 
eration only  in  those  cases  in  which  there  are  no  distinct  pile- 
tumors,  but  a  varicose  condition  involving  the  lower  rectum 
from  the  external  sphincter  upward  for  two  or  three  inches 
(5  to  7.6  centimeters)  and  the  spongy  angiomatous  mass  is  ulcer- 
ated and  protrudes  frequently.  In  such  a  condition  nothing 
short  of  excision  will  effect  a  radical  cure,  and  a  Whitehead 
operation  should  be  performed. 

If  the  operation  were  confined  to  selected  cases,  the  author 
would  have  only  words  of  commendation  for  it.  Unfortunately 
it  is  being  done  promiscuously  by  surgeons  to  the  exclusion  of 
more  simple  and  better  operations,  irrespective  of  the  number 
and  size  of  the  piles.  As  a  result,  rectal  specialists  are  con- 
stantly besieged  by  victims  of  Whitehead's  operation,  for  whom 
they  can  do  nothing  to  cure  and  little  to  alleviate. 

Failure  to  obtain  primary  union  is  the  principal  difficulty. 


452  DISEASES  OF  THE  RECTUM  AND  ANUS 

There  are  several  reasons  for  this :  (a)  tension  is  great,  the 
mucosa  is  fragile,  and  the  stitches  cut  their  way  out;  (b)  the 
straining  from  coughing  and  vomiting  after  anesthesia  is  greatest 
at  the  anus ;  (c)  infection  from  the  feces  is  of  frequent  occur- 
rence ;    (d)  it  is  difficult  to  keep  the  anus  at  rest. 

When  primary  union  is  obtained,  these  patients  assume 
their  vocation  at  the  end  of  two  or  three  weeks.  When  non- 
union follows,  the  membrane  retracts,  exposing  the  submucous 
tissue  around  the  rectum  for  one  or  two  inches  above  the  anus. 
An  ulceration  and  stricture  follow,  and  suffering  is  made  worse 
by  a  persistent  pruritus,  aggravated  by  the  constant  discharge. 
Other  operations  are  never  followed  by  such  unhappy  results, 
because  the  exposed  surface  is  in  patches  or  islands,  surrounded 
by  healthy  mncoiis  membrane,  the  elasticity  of  which  suffices  to 
compensate  for  any  cicatricial  tissue  left. 

Mr.  Whitehead  claims  that,  where  one  vein  of  the  rectum 
becomes  dilated  or  diseased,  all  will  soon  become  similarly 
involved.  Hence,  they  must  all,  even  down  to  the  smallest 
radicle,  be  excised.  Such  teachings  appears  absurd.  Surgeons 
when  operating  for  varicosities  in  other  portions  of  the  body 
never  remove  sound  veins  and  tissues  for  the  prophylactic 
effect.  The  writer  has  seen  hundreds  of  patients  who  had  suf- 
fered for  years  with  distinct  pile-tumors,  and  yet  the  interven- 
ing veins  were  normal.  Furthermore,  all  piles  are  not  the 
result  of  dilated  veins ;  on  the  contrary,  they  frequently  are 
formed  by  rupture  of  a  healthy  vein  and  the  emptying  of  blood 
into  the  neighboring  tissues  during  a  strain,  thus  forming  a 
tumor  which  will  be  temporary  or  permanent,  depending  upon 
the  rapidity  with  which  the  rent  in  the  vessel  heals. 

Does  Whitehead's  operation  insure  the  patient  against 
hemorrhoids  in  the  future?  The  author  unhesitatingly  answers 
that  it  does  not  do  so  more  than  other  recognized  operations 
properly  performed.  He  recently  saw  a  patient  who  had  been 
operated  on  several  years  before  by  the  excision  method  and 
primary  union  obtained.  This  man  had  three  large  tumors 
which  were  removed  by  the  clamp  and  cautery.  From  this  it 
is  seen  that  excision  is  not  infallible  under  the  most  favorable 
circumstances.  Hence,  this  method  should  be  discarded  for 
the  treatment  of  piles  in  general.  As  previously  stated,  it  is, 
however,  the  operation  par  excellence  for  angioniatons  masses 
involving  the  entire  circumference  of  the  lower  two  or  three 


TREATMENT  OF  INTERNAL  HEMORRHOIDS        453 

inches  (5.08  to  7.62  centimeters)  of  the  rectum.  In  conclusion, 
the  author  wih  give  a  summary  of  the  disadvantages  of  the 
Whitehead  operation.     They  are  as  fohows : — 

1.  It  is  not  suited  for  ordinary  or  even  bad  cases  of  piles. 

2.  It  is  difficult  and  bloody. 

3.  Patients  are  detained  in  bed  from  six  to  fifteen  days 

longer  than  after  the  clamp-and-cautery  or  ligature 
operation. 

4.  Owing  to  tension,  the  post-operative  pains  are  severe, 

and  may  continue  for  several  days. 

5.  Infection  is  frequent,  and  terminates  in  a  deep  or  stitch 

abscess  and  fistula. 

6.  Because  of  injury  to  the  sphincter  or  non-union,  in- 

continence, ulceration,  stricture,  and  pruritus  are 
common  sequels. 

7.  The  portion  of  bowel  between  the  anus  and  the  end  of 

the  retracted  intestine  loses  its  sensitiveness;  there 
is  also  an  absence  of  the  normal  secretion,  and  the 

special  sense  which  gives  warning  of  the  approaching 
stool  is  lost. 

8.  The   nervous   and   mental   state   of   these   sufferers   is 

pitiable  to  behold.  Many  contract  the  morphine 
habit,  while  others  turn  up  as  chronic  invalids  in 
some  sanatorium  or  asylum. 
Andrews  has  collected  200  cases  in  which  Whitehead's 
operation  was  performed,  and  summarizes  the  disastrous  re- 
sults which  occurred  as  fohows:  Loss  of  the  special  sense 
which  should  act  as  a  warning  of  approaching  stool  foUowed 
in  8  cases ;  incontinence  of  feces  in  23 ;  paralysis  of  the  sphmc- 
ter  in  4 ;  chronic  inflammation  of  the  rectum  in  1 ;  failure  of 
union  of  the  wound  by  first  intention  with  retraction  of  the 
edges  of  the  wound,  forming  a  contracting  tabular  ulcer  with 
strtcture,  in  9 ;  other  ulcers  in  2 ;  irritable  and  painful  ulcer 
in  12;  eversion  of  the  mucous  membrane  in  4;  neuralgia  of 
the  pelvis  and  inferior  extremities  in  2 ;  general  neurasthenia 
in  1 ;  fatal  peritonitis  in  1 ;  non-fatal  septic  resuhs  in  5  ;  fistula 
in  ano  in  1 ;  reported  as  having  bad  resuhs  without  accurate 
description,  127  cases.     Total.  200  cases. 

Earle's  Modification  of  Whitehead's  Operation,  as  described 
by  the  originator,  is  as  follows : — 

"With  a  case  of  mixed  hemorrhoids  involving  the  entire 


454  DISEASES  OF  THE  RECTUM  AND  ANUS 

circumference  of  the  anal  orifice :  if  there  are  only  one  or  two 
single  hemorrhoids,  then  each  can  be  dealt  with  separately  in 
a  similar  manner,  except  that  the  forceps  can  then  be  applied 
parallel  with  the  long  axis  of  the  rectum ;  the  skin  is  caught 
at  each  quadrant  of  the  anal  orifice,  just  at  the  white  line  of 
Hilton,  with  hemostatic  forceps,  and  with  them  the  skin  and 
mucous  membrane  is  pulled  down;  this  brings  into  view  any 
internal  hemorrhoids  that  may  exist,  when  they  also  are 
caught  with  hemostats  and  drawn  well  down.  An  incision  is 
then  made  at  the  center  of  the  anal  orifice  posteriorly,  suffi- 
ciently deep  to  allow  Earle's  clamp-forceps  (Fig.  153)  to  be 
applied  at  right  angles  to  the  long  axis  of  the  rectum,  and 
at  the  same  time  to  include  in  the  forceps  the  amount  of  tissue 
to  be  removed  in  this  part  of  the  zone,  care  being  taken  to  in- 


Fig.  153. — Earle's  Clamp-forceps. 


elude  in  the  forceps  more  of  the  mucous  membrane  than  the 
skin.  Before  applying  the  forceps,  the  first  two  stitches  to 
draw  together  the  skin  and  mucous  membrane  should  be  taken 
at  the  bottom  of  the  incision.  With  the  forceps  now  applied 
and  held  in  position  the  tissue  above  the  forceps  is  cut  away, 
and  a  running  suture  is  begun  by  passing  it  first  under,  and 
then  over  the  forceps,  until  the  end  of  the  forceps  is  reached, 
when  they  are  withdrawn,  and  the  suture  is  drawn  taut.  An- 
other similar  bite  of  the  redundant  tissues  is  taken  in  the  same 
manner  with  the  forceps,  cut  ofif,  sutured,  and  so  on,  until  the 
entire  redundant  tissue  is  removed,  including  all  piles  from 
the  orifice,  and  the  cut  edges  of  the  skin  and  mucous  mem- 
brane are  nicely  apposed  by  the  running  suture,  the  skin  being 
turned  in,  which  is  accomplished  by  sewing  from  within  out- 
ward.    All  hemorrhage  is  controlled  by  the  running  suture, 


TREATMENT  OF  INTERNAL  HEMORRHOIDS        455 

and  cut  surfaces  are  protected  from  infection  during  the  opera- 
tion by  being  held  by  the  forceps  after  being  cut,  until  they 
are  drawn  together  permanently  by  the  running  suture.  Me- 
dium chromicized  catgut  should  be  used. 

"The  pain  that  ensues  should  be  controlled  first  by  hypo- 
dermics of  morphine,  then  by  acetanilid  and  codeine  sulphate. 
The  wound  is  dressed  four  or  five  times  in  twenty-four  hours, 
with  a  solution  of  carbolic  acid,  1  to  40.  The  bowels  are  moved 
on  the  fourth  day;  the  patient  is  allowed  to  get  out  of  bed 
the  afternoon  of  the  same  day,  and  generally  leaves  the  hos- 
pital on  the  seventh  day." 

Pennington's  Method  of  Enucleating  Hemorrhoids  is  described 
by  himself  as  follows  : — 

"Each  anal  quadrant  is  grasped  at  the  muco-cutaneous 
junction  with  a  pair  of  T-forceps.  By  means  of  these  the  anus 
is  everted  and  the  internal  tumors  exposed.  Now,  seizing  with 
the  full  hand  the  forceps  attached  to  the  posterior  quadrant, 
evert  it,  and  with  a  pair  of  scissors  sharply  curved  on  the  flat 
remove  an  ellipse  from  the  apex  of  the  hemorrhoid  com- 
mensurate with  the  size  of  the  tumor.  All  of  the  angiomatous 
tissue  is  then  removed,  when  the  remaining  wall  collapses. 
Each  quadrant  in  regular  order  is  treated  in  like  manner.  A 
stream  of  hot  saline  solution  (115°  to  125°  F.)  flows  over  the 
field  continuously  during  the  operation.  Spurting  vessels,  if 
any,  are  caught  with  a  pair  of  forceps  and  thoroughly  twisted. 
The  T-forceps  are  now  removed,  and  all  external  tumors  and 
tabs  of  skin  cut  off.  The  field  is  dusted  with  some  antiseptic 
powder  and  a  rubber-covered  tampon  introduced  through  a 
bivalve  speculum.  By  dressing  the  patient  in  this  manner,  a 
fibrinous  exudate  is  deposited  over  the  operated  field,  which 
exudate  is  neither  destroyed  nor  disturbed  upon  removal  of  the 
dressings.  Moreover,  the  danger  of  stricture  is  obviated,  as 
the  normal  caliber  of  the  bowel  is  left  practically  covered  with 
mucous  membrane.  At  the  end  of  forty-eight  hours  the  pa- 
tient is  given  a  cathartic,  the  tampon  removed,  and  the  usual 
after-treatment  observed." 

The  Injection  of  Caustic  or  Astringent  Fluids  in  the  treat- 
ment of  piles  was  for  a  number  of  years  confined  almost  ex- 
clusively to  quacks,  who  went  about  the  country  advertising 
to  cure  piles  without  the  knife  or  the  necessity  of  the  patient's 
absenting    himself    from    his    daily    vocation.      The    injection 


45 G  DISEASES  OF  THE  RECTUM  AND  ANUS 

method  is  supposed  to  have  been  originated  by  a  young  phy- 
sician named  Mitchel,  a  resident  of  CHnton,  111.,  who  later  sold 
his  secret  to  itinerants,  who  in  a  short  time  distributed  them- 
selves throughout  the  country.  It  can  be  said  to  their  credit 
that  they  made  many  remarkable  cures ;  and  the  treatment  of 
piles,  as  well  as  of  some  other  forms  of  rectal  disease,  was,  as 
a  result,  taken  out  of  the  hands  of  reputable  physicians  and 
turned  over  to  these  quacks.  This  awakened  the  profession 
to  the  fact  that  many  patients  who  were  able  to  pay  good  fees 
were  lost  to  them,  and  that  if  they  did  not  expose  the  fraud, 
if  it  were  one,  or  learn  the  secret,  that  they  might  give  their 
patients  the  benefit  of  it,  the  profession  would  be  disgraced. 
Working  along  this  line,  Andrews,  of  Chicago,  in  1876,  ob- 
tained the  secret,  and  after  further  investigation  found  that  his 
information  was  correct.  He  then  communicated  with  a  num- 
ber of  itinerants,  and  also  with  a  number  of  regular  physicians 
who  had  been  observing  the  practice  of  these  men,  and  ascer- 
tained that  Mitchel  started  out  by  using  1  part  of  carbolic  acid 
to  2  parts  of  olive-oil.  Some  of  his  followers  discarded  the 
acid  and  tried  all  sorts  of  injections,  but  sooner  or  later  re- 
turned to  carbolic  acid.  Andrews  says  that  the  ingredients 
used  were  oil,  glycerin,  or  alcohol,  to  which  water  was  some- 
times added.  The  strength  of  the  carbolic  acid  used  varied 
from  20  to  100  per  cent.  Out  of  3304  cases  treated  by  this 
method,  13  deaths  were  reported,  and  in  addition  there  were 
numerous  cases  of  abscesses,  hemorrhage,  and  other  compli- 
cations. In  his  work  on  rectal  and  anal  surgery  Andrews  has 
compiled  the  prescriptions  used  by  the  various  itinerants. 

After  the  publication  of  the  method  of  the  quacks  many 
reputable  surgeons  became  overzealous  in  commending  the 
injection  treatment  of  piles.  Kelsey  published  a  report  of  two 
hundred  cases  so  treated,  claiming  that  the  method  was  easy 
and  certain,  especially  in  cases  of  long  standing,  and  that  the 
piles  could  be  cured  without  risk,  pain,  or  delay  from  business. 
But  at  a  later  date,  in  his  text-book  on  diseases  of  the  rectum, 
he  says  that,  while  for  a  year  he  used  the  method  almost  ex- 
clusively, he  now  uses  it  "only  in  selected  cases."  One  cannot 
help  admiring  the  candor  displayed  by  him  in  so  manfully 
recording  his  changed  views. 

The  injection  method  has  been  condemned  by  most  of 
the  surgeons  in  both  Europe  and  America.     All  agree  that  it 


TREATMENT  OF  INTERNAL  HEMORRHOIDS         457 

is  not  the  proper  treatment  for  piles  in  general,  and  that,  when 
used  at  all,  the  cases  should  he  selected  ivith  care.  The  author 
heartily  concurs  in  this  opinion,  for  he  has  witnessed  many  signal 
failures  and  much  suffering  following  the  too  promiscuous  injec- 
tion of  pile-tumors  with  caustic  or  astringent  remedies.  Hemor- 
rhoids should  never  be  injected  under  the  following  conditions : — 

1.  When  strangulated.  5.  When  large  and  hyper- 

2.  When  highly  inflamed.  trophied. 

3.  When  ulcerated.  6.  When    they    remain 

4.  When  external.  within  the   grasp   of 

the  sphincter. 

Too  much  care  cannot  be  observed  in  the  selection  of  the 
kind  of  piles  to  inject,  for,  when  it  is  promiscuously  done,  one 
or  more  of  the  following  complications  are  likely  to  arise : — 

1.  Much  pain   and   swell-      5.  Fistula. 

ing.  6.   Phlebitis. 

2.  Sphincteralgia.  7.  Pyemia. 

3.  Ulceration  or  extensive      8.  Long  delay  from  busi- 

sloughing.  .  ness. 

4.  Abscesses.  9.  Death  from  embolism. 

10.  Imperfect  cure. 

The  advantages  claimed  for  the  injection  method  by  its 
advocates  are :  (a)  no  cutting  is  done,  (h)  general  anesthesia 
is  not  necessary,  (c)  it  is  painless,  and  (d)  the  patient  is  not 
confined  to  bed  or  detained  from  business. 

In  the  author's  opinion,  only  small  piles  which  bleed  freely 
and  are  situated  above  the  grasp  of  the  sphincter-muscle  should 
he  injected}  If  this  rule  is  followed,  a  cure  may  be  effected 
without  much  suffering  or  any  delay  from  business ;  and  persons 
thus  cured  are  ever  grateful. 

If,  on  examination,  it  is  found  that  the  case  at  hand  is  suit- 
able for  the  injection  method,  the  patient  should  be  informed 
that  in  all  probability  there  will  be  some  pain  for  a  short  time 
after  the  injection,  and  that  the  operation  may  have  to  be  re- 
peated one,  two,  three,  or  more  times,  depending  upon  the  size 
and  number  of  piles  present. 

'Even  in  such  cases,  the  author  prefers  a  radical  operation,  under  local  anesthesia  as 
described  in  Chapter  XLI. 


458  DISEASES  OF  THE  EECTUM  AND  ANUS 

Tlie  preparation  for  this  method  of  treatment  consists  in  giv- 
ing some  mild  cathartic  the  morning  previous.  This  should  be 
followed  by  an  injection  of  warm  water  or  Castile  soap-suds 
shortly  before  the  operation,  to  thoroughly  empty  the  bowel 
and  to  make  the  tumors  more  prominent.  After  placing  the 
patient  in  the  position  most  favorable  for  light,  preferably  the 
Sims,  each  tumor  should  be  exposed  separately,  by  the  aid  of 
the  author's  small  hinged  speculum,  and  injected.  In  perform- 
ing the  operation  the  following  rules  must  be  observed : — 

1.  Cleanse  the  anus  and  surrounding  parts. 

2.  Make  a  fresh  solution  for  each  injection. 

3.  Place  the  syringe  and  needle  in  boiling  water  until 
everything  is  in  readiness. 

4.  Accurately  gauge  the  amount  to  be  injected. 

5.  Force  the  air  out  before  introducing  the  needle. 

6.  Inject  the  fluid  slowly  into  the  pendulous  portion  of  the 
pile. 


Fig.  154.— Gant's  Hemorrhoidal  and  Fistula  Syringe.  The  Curved  Exten- 
sion Piece  Raises  the  Needle  Above  the  Body  of  the  Syringe  and  Thereby 
Prevents  it  Obstructing  the  View  when  the   Injection   is   Made. 

7.  Inject  from  5  to  10  drops  into  small  and  from  10  to 
20  drops  into  large  piles. 

8.  Leave  the  needle  within  until  the  pile  turns  white. 

9.  Do  not  inject  the  tissue  beneath  the  pile. 

10.  As  the  needle  is  withdrawn  make  pressure  with  the 
index  finger  to  prevent  the  escape  of  the  fluid  and  arrest  hem- 
orrhage. 

11.  Promptly  return  above  the  sphincter  all  prolapsed  or 
injected  piles. 

12.  Keep  patient  in  recumbent  position  for  a  short  time 
after  operation. 

13.  A  fluid  or  semisolid  diet  is  best  for  a  few  days. 

14.  Use  moderately  weak  in  preference  to  strong  solu- 
tions. 

15.  Inject  only  one  or  two  piles  at  a  sitting. 


TREATMENT  OF  INTERNAL  HEMORRHOIDS  459 

A  good  light,  a  suitable  table,  an  ordinary  hypodermic 
syringe  with  side-bar  and  needle  with  a  long  shaft  having  a 
shoulder  to  prevent  too  deep  insertion  (Fig.  154),  a  hinged 
speculum,  together  with  suitable  dressings,  are  all  that  are 
needed  in  carrying  out  the  injection  method.  If  the  syringe 
has  a  curved  extension  piece  (Fig.  154),  so  much  the  better. 

Many  solutions  have  been  suggested  as  injections  for  the 
treatment  of  hemorrhoids.  Almost  all  of  the  caustic  and  as- 
tringent agents  of  both  the  vegetable  and  mineral  kingdoms 
have  been  tried,  and  have  their  respective  advocates.  The 
agents  which  have  given  the  best  results  are  carbolic  acid, 
iron  perchloride,  ergotine,  chloral,  zinc  sulphate  and  tannic 
acid,  alcohol,  etc.  Of  these,  carbolic  acid  in  some  form  is,  by 
the  far,  the  most  reliable  and  may  be  combined  in  solutions  of 
varying  strengths  with  olive-oil,  glycerin,  sperm-oil,  alcohol, 
or  water.  Yount,  of  Lafayette,  Ind.,  who  is  an  enthusiast  upon 
the  treatment  of  hemorrhoids  by  the  injection  plan,  prefers  a 
3-  to  5-per-cent.  solution,  while  Agnew,  of  San  Francisco,  who 
has  had  remarkable  success  with  the  injection  method,  main- 
tains that  a  solution  not  less  than  50  per  cent,  should  be  used. 
The  author  uses  the  following  formula,  which  should  be  made 
fresh  just  before  each  treatment : — 

IJ  Acidi  carbolici, 
Glycerini, 
Aqua aa  3j  41 

M.     Sig.:    Inject  from  five  to  twenty  drops. 

Numerous  formulas  have  been  used  in  the  injection  treat- 
ment of  piles.  Space  will  not  permit  a  resume  of  all  the  pre- 
scriptions which  have  been  suggested ;  hence,  only  those  com- 
binations which  have  been  successfully  employed  will  be 
given : — 

Shuford  uses : — 

3  Sodii  biboratis, 

Acidi  salicylici   aa  3j  4 

Glycerini    Bj  30 

Acidi  carbolici   3iij  12 

Misce. 

Yount  advocates : — 

IJ  Acidi  ca,rbolici   gr.  xxiv     1  56 

Aquae  destillatse Bj  30 

M.  (5  per  cent.). 


460  DISEASES  OF  THE  RECTUM  AND  ANUS 

Overall  recommends : — 

IJ  Acidi  carbolici    'v 

Fl.   ext.   ergotse (  equal  parts. 

Ulei   olivse    \ 

Misce. 

Powell  prefers : — 

I^,  Acidi  carbolici    gr.  xiij      78 

Tr.  thujae 3j  4 

Aquge  destillatae    q.   s.   ut   fiat  §ss         15 

Misce. 

Agnew  highly  recommends  the  following  combinations, 
which  the  writer  has  frequently  used  and  found  very  efTect- 
ual : — 

I^  Plumbi  acetatiSj 

Sodii  biboratis  aa  3ij  81 

Glycerini §j  30| 

Mix  as  follows:  Place  the  container  in  a  warm  bath  for  fifteen  minutes 
to  hasten  the  solution  of  the  salts,  and  allow  the  mixture  to  stand  for  twenty- 
four  hours.  The  glycerin  and  graduate  should  be  warmad  to  facilitate  ac- 
curate measurement;  the  other  ingredients  should  then  be  added.  A  suffi- 
cient quantity  of  Calvert's  No.  1  crystallized  carbolic  acid  should  now  be 
liquefied  by  heat,  and  1  ounce  (30  cubic  centimeters)  of  it  taken  and  mixed 
with  2  drachms  (8  cubic  centimeters)  of  distilled  water.  A  sufficient  quantity 
of  lead  glyceride  and  borax  (see  prescription  above)  previously  prepared  is 
then  added  to  make  exactly  2  ounces   (60  cubic  centimeters). 

IJ  Acidi  carbolici  crystallisatus Hj  30| 

Aquse  destillatse    3ij  4 

Sodii  biboratis  et  plumbi  glyc 3vj        24 

Misce. 

Carl  Beck,  of  New  York,  has  obtained  good  results  from 
injecting  2  drops  of  a  saturated  solution  of  iodoform  in  ether 
into  the  cellular  tissue  on  each  side  of  the  pile. 

The  following  are  said  by  Andrews  to  be  the  combinations 
formerly  held  secret  by  the  more  prominent  itinerant  pile- 
doctors.     The  Brinkerhoff  secret  remedy  is  composed  of: — 

IJ  Acidi  carbolici   §j  30 

Zinci  chloridi    .  .  .' gr.  viij  52 

Olei  olivaj    8v  150 

The  "Rorick  system"  is  a  combination  of: — 

IJ  Acidi  carbolici  3j 

Glycerini    3ij 

Ext.  ergotaj  Huidi   3j 

Aquae    3ij 


TREATMENT  OF  INTERNAL  HEMORRHOIDS  4G1 

S.  Green's  "painless  injection"  consists  of: — 

fj  Acidi  carbolici   Bj  30 

Creasoti   gtts.  x       31 

Acidi  hydrocyanici   gtt.  j         03 

Olei  oliv«   Sj  30 

Mix  and  unite  under  water. 

Submucous  Ligation. — Dr.  Merrill  Ricketts,  of  Cincinnati, 
a  few  years  since,  devised  a  submucous  operation  for  hem- 
orrhoids which  is  performed  after  the  following  method :  After 
thorough    divulsion    of    the    sphincter    a    large,    semicircular 


■ 

K 

^E 

1 

■ 

^^S,  ''*  'ii':^^ '    \ 

dS  •'*i-i 

«      «^K' 

^-if                      'mMmml 

t 

iwm 

Fig.  155.— Showing  Submucous  Ligation  of  Hemorrhoids. 

needle  carrying  a  silk  ligature  is  introduced  subcutaneously 
from  the  muco-cutaneous  line  to  the  upper  border  of  the  pile- 
bearing  area  and  then  returned  to  make  its  exit  at  the  point 
of  entrance.  The  needle  is  then  removed  and  the  ligature  made 
taut  above  the  venous  plexus  and  the  ends  left  hanging  out 
(Fig.  155).  These  ligatures  may  be  from  one-half  to  one 
inch  (1.3  to  2.54  centimeters)  apart,  as  the  case  may  require, 
and  are  allowed  to  come  away  spontaneously.  According  to 
its  originator,  it  is  not  necessary  to  tie  all  the  varices  in  this 
operation,  as  the  atrophic  changes  which  follow  will  necessarily 
obhterate  the  remaining  piles.  The  advantages  claimed  for 
this  operation  are :    no  tissue  is  sacrificed :    the  mucous  mem- 


462  DISEASES  OF  THE  RECTUM  AND  ANUS 

brane  remains  intact;  there  is  no  hemorrhage,  infection,  or 
pain  of  consequence;    and  the  loss  of  time  is  practically  nil. 

The  author  has  performed  this  operation  five  times,  and 
the  results  obtained  were  such  as  to  convince  him  that  it  has 
no  advantages  over  either  the  clamp-and-cautery  or  the  liga- 
ture operation.  In  two  cases  in  which  the  hemorrhoids  were 
of  moderate  size  and  protruded,  sufficient  atrophy  took  place 
to  prevent  their  descent.  In  the  third  case — in  which  the 
pile-tumors  were  large,  ulcerated,  and  bled  freely — they  were 
slightly  diminished  in  size ;  the  hemorrhages  continued,  how- 
ever, and  the  patient  was  finally  relieved  by  a  clamp-and-cau- 
tery operation.  In  the  fourth  case  the  hemorrhoidal  condition 
was  improved,  but  infection  occurred ;  this  resulted  in  the 
formation  of  an  abscess,  which  terminated  in  fistula,  requiring 
another  operation  at  a  later  date.  The  fifth  was  a  very  ag- 
gravated case;  there  were  four  very  large  hypertrophied, 
ulcerated,  and  protruding  internal  hemorrhoids,  thus  necessi- 
tating the  application  of  several  ligatures.  The  patient  suf- 
fered intensely  during  the  first  three  days,  and  was  unable  to 
void  his  urine;  the  tumors  became  so  swollen  that  it  was 
impossible  to  prevent  protrusion.  He  was  kept  quiet  with 
morphine  and  the  inflammation  reduced  by  cold  and  astringent 
applications,  but  he  was  unable  to  leave  the  hospital  before  the 
end  of  the  third  week.  It  was  four  weeks  before  the  soreness 
caused  by  the  operation  disappeared  and  the  patient  was  able 
to  return  to  his  work.  The  author  made  an  examination  three 
months  after  the  operation  and  found  that,  while  there  had 
been  some  atrophy,  the  tumors  were  firm  and  sufficiently  large 
to  protrude  during  stool.  In  all  cases  in  which  the  piles  were 
large  it  was  impossible  to  encircle  them  without  bringing  the 
needle  out  at  a  half-way  point  and  again  introducing  it  to  com- 
plete the  circle. 

Based  upon  his  experience  in  these  cases,  the  author  would 
suggest  that,  while  this  operation  is  useful  in  some  cases,  it  is 
not  entitled  to  precedence  over  the  clamp-and-cautery  and  liga- 
ture operations  because :  (a)  it  is  not  as  effective ;  (b)  it  causes 
as  much,  if  not  more,  pain  and  vesical  disturbances ;  (c)  it  re- 
quires a  longer  time  to  perform  the  operation ; ,  (d)  it  does 
not  remove  redundant  tissue;  (e)  there  is  always  great  danger 
of   infection   in   needle-wounds;     (fj    it   takes   as   long,    if   not 


TREATMENT  OF  INTERNAL  HEMORRHOIDS        463 

longer,  to  effect  a  cure ;   and  (g)  finally  the  operation  is  more 
difficult  for  the  inexperienced  to  perform. 

Cauterization  may  be  used  in  one  of  three  ways,  viz. : — 

1.  By  puncture  (Reeves). 

2.  Linear. 

3.  Galvanocautery-wire. 

Cauterization  by  Puncturing  the  piles  was  used  by  ancient 
surgeons,  and  has  been  revived  from  time  to  time.  Mr. 
Reeves,  an  eminent  surgeon  of  London,  a  few  years  ago  en- 
deavored to  popularize  this  operation,  but  failed. 

Allingham,  Sr.,  tried  the  same  method  in  three  cases,  and 
says  it  was  a  failure  in  all :  great  pain,  retarded  recovery,  and 
abscesses  occurred  in  two  cases,  and  the  third  was  not  cured. 
The  author  has  tried  this  operation  in  a  number  of  cases,  and  his 
experience  has  been  so  extremely  unsatisfactory  that  he  will 
not  attempt  it  again,  for  the  reason  that  other  operations  which 
are  accompanied  by  fewer  complications  give  much  better 
results. 

Linear  Cauterisation  was  introduced  in  1875  by  Voillemeir. 
He  applied  the  cautery  to  the  mucous  membrane  within  the 
anus,  before,  behind,  to  the  right  and  left  sides  of  the  bowel, 
and  not  directly  to  the  piles.  The  parts,  as  a  rule,  were  much 
swollen  for  a  few  days,  during  which  time  water  dressings  and 
poultices  were  applied.  The  pain  is  quite  severe  for  about 
four  days,  and  the  time  for  a  cure  never  exceeds  one  month. 
The  benefit  derived  is  from  the  contraction,  which  is  never 
enough  to  produce  a  stricture.  The  author  has  resorted  to  this 
method  and  found  it  to  be  very  inefficient  for  ordinary  piles, 
because  of  the  great  pain,  delayed  healing,  and  imperfect  re- 
sults. He  practices  hnear  cauterization  by  applying  the  cau- 
tery-point directly  to  the  tumors  after  the  sphincter  has  been 
divulsed,  to  prevent  after-pain.  The  patients  are  never  con- 
fined to  bed  after  the  second  day,  but  are  allowed  to  sit  up  in 
a  comfortable  chair,  and  at  the  end  of  the  fifth  day  are  dis- 
charged with  instructions  to  return  twice  a  week  in  order  that 
some  stimulating  application  may  be  applied  to  any  unhealed 
ulcers.  This  operation  is  not  suitable  in  long-standing  cases 
in  which  the  tumors  are  large,  numerous,  h5'pertrophied,  or 
ulcerated.  On  the  other  hand,  it  is  of  service  in  cases  in  which 
no  distinct  pile-tumors  are  present,  but  a  general  varicose  con- 


464 


DISEASES  OF  THE  RECTUM  AND  ANUS 


dition  on  all  sides  of  the  lower  rectum  exists,  along  with  a 
tendency  of  the  mucous  membrane  to  protrude. 

The  Use  of  the  Galvanocautery-wire  for  the  removal  of  piles 
is  from  time  to  time  revived,  only  to  be  condemned  after  a 
short  trial.  The  author  has  never  seen  a  case  in  which  he  felt 
justified  in  resorting  to  its  use,  principally  on  account  of  the 


Fig.  156. — Pollock's  Hemorrhoidal  Crusher. 


unreliability  of  the  batteries.  Furthermore,  he  cannot  see  that 
it  possesses  any  advantage  over  the  Paquelin  or  actual  cautery. 
Thorough  Divulsion  of  the  sphincter-muscles  for  the  cure  of 
internal  piles  is  highly  spoken  of  by  eminent  French  surgeons, 
such  as  Verneuil,  Gosselin,  Fontan,  and  many  others.  The 
operation  is  performed  by  inserting  the  two  tliumbs  within 
the  anus  and  gradually  overpowering  the  sphincter  by  gentle 
and  constant  pressure  in  every  direction  (Fig.  140).     At  the 


Fig.  157. — Herbert  Allingham's  Pile-crusher. 

same  time  care  must  be  observed  to  avoid  lacerating  the  mu- 
cous membrane  or  the  muscles.  Unless  the  patient  absolutely 
refuses,  it  is  best  to  do  this  under  general  anesthesia.  Divul- 
sion can  be  accomplished,  however,  by  the  use  of  rubber  bou- 
gies, but  this  method  causes  more  annoyance,  requires  a  longer 
time,  and  the  results  are  not  so  good. 

The  ooeration  of  dilatation  has  not  proven  satisfactory  in 


TREATMENT  OF  INTERNAL  HEMORRHOIDS 


465 


the  author's  hands,  except  in  cases  in  which  the  timiors  were 
small  and  the  sphincters  tight.  In  such  cases,  as  well  as  those 
complicated  with  an  irritable  ulcer  or  fissure  which  induces 
great  suffering,  we  have  relieved  patients  by  this  simple  pro- 
cedure. Two  days  after  the  operation  the  sphincters  are  capable 
of  acting,  but  the  spasm  is  gone.  The  bowel  acts  freely,  and 
the  only  indication  that  the  operation  has  been  performed  is 
a  slight  extravasation  of  blood  about  the  anus.  It  never  de- 
tains the  patient  from  business  more  than  three  days.  This 
method  is  not  at  all  suited  for  the  treatment  of  large,  protruding 
hemorrhoids,  because  none  of  the  redundant  tissue  is  destroyed 
or  removed. 


Fig.   158. — Appearance  of  Hemorrhoids  Before  Crushing  Operation. 


The  Crushing  Method  of  curing  piles  is  an  old  one  which 
has  recently  been  revived  with  the  advent  of  the  angiotribe. 
The  operation  was  introduced  by  Mr.  George  Pollock,  in  1880; 
and  in  1885  Allingham,  Jr.,  began  advocating  it,  but  substi- 
tuted for  the  pincher-like  crusher  of  Mr.  Pollock  (Fig.  156) 
a  screw-crusher,  which  the  writer  has  seen  used  by  him 
at  St.  Mark's  Hospital,  London,  with  satisfactory  results  (Fig. 
157).  The  operation  as  performed  by  Allingham  consists  in 
drawing  the  pile  through  the  crusher,  which  is  then  tightened. 
The  projecting  portion  is  removed  with  scissors,  and  after 
twenty-five  seconds  the  crusher  is  taken  off.  He  advises  its  use 
only  when  the  piles  are  small  and  fezv  in  number. 


46G 


DISEASES  OF  THE  RECTUM  AND  ANUS 


The  operation  as  performed  by  the  author  with  the  angio- 
tribe  or  his  clamp  is  similar  to  one  just  described  (Figs.  158 
and  159). 

The  operation  is  not  likely  to  become  popular  in  this 
country,  for  many  of  our  surgeons  prefer  the  injection  method, 
which  is  suitable  only  for  that  class  of  cases  in  which  Ailing- 
ham  uses  his  crusher.  The  operation  has  some  points  which 
merit  consideration :  there  is  comparatively  little  danger  from 
hemorrhage,  a  shorter  time  is  required  for  recovery,  and  suffer- 
ing is  less  than  when  ligation  is  performed. 

Manley,  of  New  York,  advocates  crushing  piles  between 
the  thumb  and  forefinger.     The  technic  of  this  operation  is  as 


Fig.  159. — Appearance  of  Lower  Rectum  After  Crushing  Operation 
for  Hemorrhoids. 


follows :  After  the  tumors  have  been  cocainized  the  sphincter  is 
divulsed  and  each  tumor  is  in  turn  seized  close  to  its  base  be- 
tween the  thumb  and  index  finger  and  put  on  a  strain  (tension) ; 
it  is  then  twisted  completely  around  on  its  axis  (torsion);  last, 
it  is  crushed  to  a  pulp  (compression).  The  crushed  mass  is  then 
returned  above  the  sphincter.  According  to  Manley,  the 
operation  is  promptly  followed  by  inflammatory  reaction  and 
absorption  of  the  core  and  hemorrhagic  detritus. 

It  seems  to  the  author  that  this  method  would  be  of  service 
only  when  piles  are  in  their  incipiency,  and  be  beneficial  for  but 
a  short  time. 


TREATMENT  OP  INTERNAL  HEMORRHOIDS  467 

The  Ecraseur  Method  of  removing  hemorrhoids  is  highly 
recommended  by  French  writers.  EngHsh  and  American  sur- 
geons, however,  with  few  exceptions  condemn  this  operation, 
for  the  reason  that  with  either  the  wire  or  chain  it  is  impos- 
sible to  remove,  with  any  degree  of  accuracy,  the  desired  amount 
of  pile-tissue.  Sometimes  too  little  will  be  removed,  making 
the  operation  a  failure;  at  another  time  too  much,  causing  con- 
striction to  a  greater  or  less  degree.  The  author  has  operated 
with  the  ecraseur  but  a  few  times.  In  each  instance  the  results 
were  unsatisfactory,  and  he  has  discarded  this  method  of  treat- 
ment. 

Applications  of  a  Chemic  Caustic  are  not  indicated  in  cases 
where  the  tumors  are  large  and  protruded,  but  are  useful  in 
the  small,  flat,  capillary  variety. 

Many  acids  have  been  recommended  for  this  purpose. 
Nitric  acid,  however,  seems  to  outrank  them  all,  though 
chromic  and  carbolic  acids  have  their  respective  adherents. 
The  writer  has  seen  a  few  cases  in  which  hemorrhage  was  per- 
manently arrested  by  this  means;  in  other  instances  cauter- 
ization did  no  good  or  controlled  the  bleeding  for  a  short  period 
only.  He  recalls  one  patient  who,  as  a  result  of  this  treatment, 
nearly  bled  to  death  when  the  slough  came  away.  The  neigh- 
boring parts  should  be  protected  with  vaselin,  and  all  excess  of 
the  acid  be  neutralized  with  soda.  The  applications  may  be 
made  to  the  exposed  pile  with  a  swab  made  of  absorbent  cotton 
twisted  firmly  around  a  tooth-pick  or  with  a  glass  rod.  Some 
prefer  caustic  paste  for  destroying  the  hemorrhoids,  but  its  uss 
is  attended  by  more  danger.- 

The  After-treatment  following  hemorrhoidal  operations  is 
simple,  but  most  important.  During  the  first  thirty-six  hours 
sufficient  morphine  should  be  given  (when  necessary)  to  ease 
the  pain  and  keep  the  patient  perfectly  quiet  in  order  to  lessen 
the  danger  of  hemorrhage.  Some  authorities  recommend  for 
this  purpose  the  introduction  of  suppositories  containing  mor- 
phine, opium,  belladonna,  eucaine,  or  cocaine.  They  are  not 
desirable  in  many  cases  because  of  the  irritation  produced 
and  the  tendency  of  the  patient  to  expel  them.  The  diet  should 
be  fluid  or  semisolid  during  the  first  week.  Nothing  should 
he  given  to  tie  up  the  bozvels,  because  this  is  unnecessary  if 
the  patient  has  been  properly  prepared.  On  the  fourth  day 
after  the  operation  salts,   licorice-powder,   Carabaha  water,   or 


468  DISEASES  OF  THE  RECTUM  AND  ANUS 

Other  cathartic  should  be  prescribed.  The  patient's  comfort 
depends  much  upon  the  character  of  the  stool  during  the  first 
week,  and  it  is  desirable  that  they  should  be  soft  or  semi- 
solid in  consistence.  To  accomplish  this  the  author  orders 
2  ounces  of  Carabana  water  to  be  taken  in  a  tumblerful  of 
warm  water  every  morning  before  breakfast.  If  from  any 
cause  the  feces  should  become  impacted,  they  may  be  removed 
by  copious  injections  of  warm  water  containing  Castile  soap 
and  oil  or  glycerin.  When  these  fail,  the  fecal  accumulation 
should  be  broken  up  with  the  finger,  and  then  washed  out. 
The  writer  never  places  dressings  of  any  kind  in  the  rectum 
after  the  clamp-and-caiitery  or  ligature  operations.  Since  he 
adopted  this  plan  his  patients  have  suffered  much  less  than 
formerly,  when  a  large  rubber  tube  wrapped  with  gauze  was 
left  protruding  from  the  rectum.  After  the  sphincter  has  been 
divulsed,  if  any  gas  forms  in  the  bowel  during  the  first  twenty- 
four  hours,  the  bandage  and  wedge-shaped  compress  should  be 
temporarily  removed ;  this  will  allow  the  gas  to  escape.  The 
only  dressing  necessary  in  these  cases  is  to  bathe  the  anus  with 
water  as  hot  as  can  he  home,  each  morning  and  night,  after 
which  a  small  pad  of  gauze  is  placed  over  the  anus  and  loosely 
supported  by  a  bandage.  These  anal  baths  add  much  to  the 
patient's  comfort  by  allaying  pain,  diminishing  irritability  of 
the  sphincter,  and  forestalling  pruritus,  which  might  otherwise 
ensue  as  the  result  of  accumulated  discharge.  Active  exercise 
should  be  prohibited  for  the  first  week  or  two  after  the  opera- 
tion. These  patients  should  be  kept  under  observation  until 
the  ulcers  have  entirely  healed.  In  cases  where  ulcers  are  in- 
clined to  become  chronic,  they  should  be  stimulated  with  silver 
nitrate,  balsam  of  Peru,  or  ichthyol. 

ILLUSTRATIVE  CASES 

Case  XXXII.  Internal  Hemorrhoids  Treated  by  the  Injection  Method. 
— Mr.  L.  M.,  aged  43,  banker  by  occupation,  came  to  me  to  be  treated  for  piles. 
He  insisted  on  treatment  by  the  injection  method,  so  as  to  avoid  chloroform 
and  detention  from  business.  On  examination  four  congested  piles  were 
found  which  partially  protruded.  A  more  certain  and  radical  operation  was 
advised,  but  he  would  not  submit  to  it.  I  then  fully  explained  to  him  that 
complications  might  arise  vvhich  would  cause  him  some  pain  and  delay  from 
business.  He  was  also  told  that  a  permanent  cure  could  not  be  promised; 
but  that,  if,  in  spite  of  these  facts,  he  so  desired,  I  would  do  the  best  I 
could  for  him.  He  instructed  me  to  go  ahead  with  the  treatment.  The 
bowel  was  washed  and   he  was  requested  to  bear  down;    the   tumors   were 


TREATMENT  OF  INTERNAL  HEMORRHOIDS        469 

cleansed  with  a  carbolized  solution  and  made  ready  for  the  injection,  which 
was  performed  as  follows: — 

A  hypodermic  syringe,  with  an  extension  piece  and  needle  (Gant's,  Fig. 
154),  was  boiled  and  filled  with  the  following  solution:  — 

IJ  Acidi  carbolici   gr-  xij      [78 

Gljcerini, 

Aqua aa  3j  41 

Ten  drops  were  injected  into  each  of  the  selected  tumors.  The  needle  was 
not  withdrawn  until  the  pile  turned  whitish  in  color.  The  piles  were  then 
oiled,  replaced,  and  the  patient  requested  to  remam  quiet  in  the  recumbent 
position  for  an  hour  or  so.  For  a  few  moments  he  suffered  considerable  pain, 
but  at  the  end  of  two  hours  he  went  to  the  bank,  wrote  two  letters,  and  then 
went  home  and  made  himself  comfortable.  During  the  night  he  was  restless 
and  felt  uncomfortable  about  the  rectum,  but  had  no  acute  pain.  I  saw  him  on 
the  third  day,  and  he  complained  of  nothing  but  heat  and  fullness  about  the 
anus.  It  was  deemed  best  not  to  make  an  examination,  for  the  reason  that,  ii 
the  piles  should  protrude,  his  suffering  would  be  increased  and  a  cure  delayed 
He  was'  restricted  to  a  liquid  diet,  and  a  stool  induced  every  other  day  witt 
a  saline  cathartic.  On  the  tenth  day  the  tumors  were  almost  completely 
shriveled  up.  At  this  time  the  remaining  two  were  injected  in  exactly  the 
same  way  as  the  previous  ones.  During  the  night  he  complained  of  consider- 
able pain  and  could  not  get  relief,  though  poultices  were  applied  constantly 
to  the  anus.  At  2  a.m.  and  again  at  4  a.m.  he  had  V*  grain  (15  centigrams) 
of  morphine,  which  afforded  some  relief.  The  pain  continued  on  the  second 
and  third  days  and,  in  addition,  all  the  symptoms  of  an  inflammatory  process 
were  present.  By  separating  the  anal  folds  the  mucous  membrane  appeared 
red  and  swollen,  and  there  was  every  evidence  that  an  abscess  was  forming. 
His  pulse  was  100  and  full;  temperature  103°  F.;  he  was  restless  and  con- 
stantly complained  of  pain  and  twitching  of  the  sphincter-muscle.  The  poul- 
tices were  continued.  On  the  sixth  day  the  abscess  "pointed"  a  little  below 
and  to  the  right  of  the  anus.  It  was  promptly  incised,  curetted,  irrigated, 
and  packed  with  iodoform  gauze.  Relief  was  instantaneous,  in  so  far  as  pain 
was  concerned.  While  he  was  under  the  anesthetic  I  made  a  thorough  exami- 
nation to  ferret  out  the  cause  of  the  inflammatory  process. 

I  found  that  one  of  the  tumors  had  become  indurated  and  shriveled  up, 
while  the  other  had  undergone  a  sloughing  process.  In  the  center  of  the 
tumor  where  the  injection  had  been  made  was  a  deep,  irregular,  inflamed 
ulcer,  at  the  bottom  of  which  I  found  a  small,  round,  hard  lump  of  fecal 
matter.  The  question  then  arose  in  my  mind  as  to  whether  the  septic  con- 
dition was  induced  by  an  unclean  needle,  tlie  solution  used,  or  as  a  result 
of  a  slough  caused  by  the  wound  becoming  infected  by  the  fecal  matter  at  a 
later  date.  I  am  inclined  to  believe  that  the  last  is  the  most  probable  solu- 
tion to  the  question.  The  parts  were  cleansed  daily  with  a  bichloride  solu- 
tion and  the  abscess-cavity  packed  with  gauze.  The  patient  was  conflned  to 
his  bed  for  seven  days  and  detained  from  his  business  for  ten:  a  longer  time 
tlian  if  he  had  submitted  to  the  radical  operation,  and  his  suffering  was  much 
more  severe.  At  the  same  time  he  narrowly  escaped  having  to  undergo  an 
operation  for  fistula. 


470  DISEASES  OF  THE  RECTUM  AND  ANUS 

Case  XXXIII.     Internal  Hemorrhoids  (Clamp-and-Cautery  Operation). 

— This  patient,  a  merchant  40  years  old,  and  a  man  of  exemplary  habits,  said 
he  had  sufl'ered  for  several  years  with  piles.  More  recently,  however,  they 
came  down  to  such  an  extent  as  to  interfere  with  his  attending  to  business. 
He  was  given  an  enema,  and  requested  to  bear  down.  Immediately  a  number 
of  very  large  hemorrhoids  came  into  view,  forming  a  rosette.  The  patient 
was  sent  to  All-Saints  Hospital,  Kansas  City,  and  prepared  for  the  operation, 
which  was  performed  on  the  next  afternoon,  as  follows:  The  sphincters  were 
thoroughly  divulsed,  and  each  tumor  was  in  turn  seized  with  catch-forceps, 
pulled  down,  the  skin  and  mucous  membrane  severed,  the  clamp  (author's) 
adjusted  in  the  incision,  the  tumors  pulled  farther  down,  and  the  clamp 
tightened.  Then  that  portion  of  the  pile  external  to  the  clamp  was  excised, 
the  stump  cauterized  with  a  Paquelin  cautery-point,  and  the  clamp  removed. 
A  compress  of  gauze  and  cotton  was  placed  against  the  anus  and  secured  in 
position  by  a  snug  T-bandage.  He  recovered  from  the  anesthetic  nicely  and 
was  able  to  void  his  urine  three  hours  after  the  operation  without  any  diffi- 
culty. 

Early  in  the  night  he  became  restless  and  complained  of  slight  pain; 
the  bandage  was  loosened,  and  in  a  short  time  he  went  to  sleep  and  slept 
nearly  all  night.  Once  or  twice  he  was  awakened  by  a  sudden  jerking  about 
the  anus:  a  common  symptom  after  operations  for  hemorrhoids,  which  is  due 
to  the  contraction  of  the  levator  ani  muscles.  His  bowels  did  not  act  until  the 
fourth  day,  and  then  only  after  a  dose  of  Epsom  salts  had  been  administered. 
After  each  stool  the  rectum  was  irrigated;  the  raw  surfaces  had  been  painted 
over  with  balsam  of  Peru  and  gauze  applied.  His  diet  consisted  of  liquid  and 
semisolid  foods.  At  the  end  of  the  first  week  the  patient  was  able  to  walk 
about  with  comfort.  He  was  discharged  from  the  hospital  with  instructions 
to  cleanse  the  rectum  daily  and  use  the  balsam.  In  ten  days  he  resumed  his 
business  and  said  that  he  would  not  know  that  he  had  been  operated  on 
except  for  a  slight  tenderness  about  the  anus. 

Case  XXXIV.  Internal  Hemorrhoids  Complicated  with  Ulceration 
(Ligature  Operation).— Mrs.  S.  was  referred  to  me  to  be  treated  for  a  rectal 
disease.  She  informed  me  that  she  had  been  rendered  almost  helpless  because 
of  the  daily  hemorrhage  from  the  rectum  which  followed  each  action.  In 
addition  to  this,  she  had  considerable  pain  which  she  thought  was  due  to  two 
piles  which  remained  constantly  outside  the  anus.  Until  the  beginning  of 
her  illness,  which  dated  back  one  year,  she  had  enjoyed  perfect  health  and 
weighed  140  pounds,  but  her  weight  had  decreased  to  108  pounds. 

Examination  revealed  two  large,  protruding,  internal  hemorrhoids,  which 
were  strangulated,  ulcerated,  and  exceedingly  painful.  An  enema  was  given, 
and  she  was  requested  to  strain  down.  Immediately  the  tumors  became  dis- 
tended and  commenced  to  bleed,  and  the  blood  could  be  seen  spurting  from 
the  center  of  the  ulcerated  spots. 

Operation. — I  advised  her  to  have  the  clamp-and-cautery  operation  with- 
out delay.  The  idea  that  the  cautery  was  to  be  applied  frightened  her.  She 
asked  me  to  do  the  ligature  operation,  for  a  friend  of  hers  had  been  operated 
on  in  this  manner  with  success,  and  to  this  I  consented.  An  anesthetic  was 
given,  the  sphincter  divulsed,  and  each  tumor  was,  in  turn,  seized,  pulled  down, 
the  skin  severed  at  the  mucocutaneous  junction,  and  the  piles  dissected  up 


TREATMENT  OF  INTERNAL  HEMORRHOIDS        471 

from  the  submucous  tissues  and  ligated  high  up.     The  usual  dressings  were 
applied  and  the  patient  put  to  bed. 

In  one  hour  she  was  conscious  and  was  suffering  very  little  pain.  At 
8  P.M.,  six  hours  after  the  operation,  she  became  very  restless;  she  said  the 
rectum  felt  hot,  swollen,  and  pained  her  very  much.  Cold  cloths  were  applied 
to  the  anus,  but  gave  no  relief.  One-fourth  grain  (15  centigrams)  of  morphine 
hypodermically  was  then  ordered,  which  gave  some  relief;  this  had  to  be 
repeated  in  two  hours,  after  which  she  experienced  a  fairly  comfortable  night. 
She  was  catheterized,  as  she  was  unable  to  void  her  urine,  although  hot  stupes 
had  been  applied.  Next  morning  she  was  fairly  comfortable,  but  the  urine 
had  to  be  drawn  by  catheter  for  four  days  afterward.  From  the  fourth  day 
she  complained  of  nothing  but  a  fullness  about  the  rectum  and  a  feeling  as 
if  something  were  there  which  should  come  away:  a  symptom  that  I  have 
frequently  observed  after  this  operation.  The  ligatures  came  away  on  the 
seventh  and  ninth  days,  respectively,  leaving  grayish-looking  ulcers  with 
irregular  edges.  These  were  treated  with  one  or  two  applications  of  calomel, 
to  clear  them  of  any  remaining  portion  of  the  slough.  Afterward  they  were 
treated  like  any  other  ulceration,  namely:  by  cleanliness,  stimulating  appli- 
cations, and  rest.  She  was  up  and  about  at  the  end  of  the  second  waek,  and 
dt  the  end  of  the  third  week  she  was  discharged  from  the  hospital  cured. 


IITERATURE  ON  HEMORRHOIDS   (PILES) 


Adler:     "Treatment  of  Hemorrhoids   by  the  Injection   Method,"  Therapeutic 

Gazette,  Aug.,  1897. 
Agnew:    "Hemorrhoids  and  Other  Non-malignant  Rectal  Diseases,"  1896. 
Allingham:    "Treatment  of  Hemorrhoids,"  "Diseases  of  the  Rectum  and  Anus," 

p.  84,  1888.' 
Andrews:    "Injection  Treatment  of  Hemorrhoids,"  p.  149   (third  edition). 

"Whitehead's  Operation,"  Columbus  Med.  Jour.,  No.  3,  1895. 
Ball:     "Palliative   Treatment   of   External   Hemorrhoids,"   "The   Rectum   and 

Anus,"  p.  230,  1887. 
Beck:    "Injection  Iodoform  and  Ether  Treatment  of  Hemorrhoids,"  ZV.  Y.  Med. 

Jour.,  July  21,  1894. 
Bodenhamer:    "Hemorrhoidal  Disease,"  p.  171,  1884. 
Cripps:    "Internal  Hemorrhoids,"  "Diseases  of  the  Rectum  and  Anus,"  p.  6S, 

1890. 
Dennis:    "Hemorrhoids,"  "System  of  Surgery,"  vol.  }v,  pp.  528-533,  1896. 
Earl:    "Etiology  and  Pathology  of  Hemorrhoids,"  Mathews's  Med.  Quart.,  vol. 

i,  p.  222,  1894. 

"Modification    of    Whitehead    Operation,"    Mathews's    Med.    Quart., 

vol.  iii,  p.  521,  1896. 
Engle:    Semaine  Medicale,  No.  36,  1893. 
Gant:    "Criticism  of  Whitehead's  Operation  for  Hemorrhoids,"  Virginia  Med. 

Monthly,  p.  6,  April,  1899. 
Goodsall  and  Miles:    "Hemorrhoids,"  "Disease  of  the  Anus  and  Rectum,"  Pt. 

I,  p.  251,  1900. 


473  DISEASES  OF  THE  RECTUM  AND  ANUS 

Kelsey:    "Injection  Treatment  of  Hemorrhoids,"  "Diseases  of  the  Rectum  and 

Anus,"  p.  178,  1890. 
Manley:    "Bloodless  Operation  for  Hemorrhoids,"  Mathews's  Med.  Quart.,  vol. 

i,  p.  150,  1894. 
Martin:    "A  New  Pile-clamp,"  Amer.  Gynecol,  and  Obstet.  Jour.,  Oct.,  1898. 
Pennington:    "Simple  Operation  for  Hemorrhoids,"  Intei'nat.  Jour,  of  Surg., 

Dec,  1900. 
Quensee:     "Causation   of   Hemorrhoids,"   Rev.  de  Chir.;    v.  ref.   Pacific   Med. 

Jour.,  March,  1894. 
Quenu  and  Hartmann:    "Hemorrhoids,"  "Chir.  du  Rectum,"  p.  335,  1895. 
Rechio:     "Treatment  of  Hemorrhoids  by   Dilatation,"   La  Semaine  Medlcale, 

Nov.  28,  1894. 
Ricketts:     "Submucous   Operation  for  Hemorrhoids,"  Mathews's  Med.   Quart., 

vol.  V,  p.  319,  1898. 
Sims:     "New  Operation  for  Hemorrhoids,"  Maryland  Med.  Jour.,  vol.  xxxix, 

p.  531,  1890. 
Smith:    "Clamp-and-Cautery  Operation,"  Lancet  (London),  April  20,  1878. 
Trousseau:    "Salutary  Effect  of  Hemorrhoids,"  Jour,  des  Connalsances  Medico- 

Chirur.,  p.  101,  Sept.,  1836. 
Whitehead:    "Excision  Operation  for  Hemorrhoids,"  Brit.  Med.  Jour.,  vol.  i. 

p.  448,  1882.  " 

"Report  of  Three  Hundred  Cases  Treated  by  Excision,"  iMd.,  Feb. 

26,  1887. 
Ziegler:    "Hemorrhoids,"  "Text-book  of  Spec.  Path.  Anat.,"  JSec.  1  to  Vlll,  p. 

94,  1898. 


CHAPTER  XXX 

HEMORRHAGE 

Hemorrhage  from  the  rectum  is  one  of  the  most  fre- 
quent and  alarming  symptoms  of  proctica,  and  is  often  the  first 
indication  of  rectal  disease.  It  is  more  common  in  adults  than 
in  children.  The  bleeding  may  be  slight  or  profuse  and  occur 
during  defecation,  in  the  intervals,  or  both;  the  blood  may  be 
discharged  pure,  liquid  or  in  clots,  or  mixed  with  mucus,  pus, 
feces,  or  other  debris.  Blood  discharged  per  rectum  is  usually 
from  a  local  hemorrhage,  but  may  have  descended  from  the 
stomach,  small  intestines,  colon,  or  sigmoid.  The  bleeding  in 
the  rectum  may  be  general  from  many  points,  or  it  may  come 
from  a  single  vessel  and  be  arterial  or  venous. 

ETIOLOGY   AND   PATHOLOGY 

Rectal  hemorrhage  may  be  caused  by  (1)  local  disease, 
(2)  traumatism,  or  (3)  operations. 

1.  The  Local  Diseases  of  the  rectum  which  may  cause  hem- 
orrhage are : — 


1. 

Internal  hemorrhoids. 

7. 

Proctitis. 

2. 

Prolapse. 

8. 

Fecal  impaction. 

3. 

Fissures. 

9. 

Polyps. 

4. 

Ulceration. 

10. 

Villous  growths. 

5. 

Stricture. 

11. 

Chancroids    and 

6. 

Malignant  disease. 

cres. 

chan- 

res. 
12.   Condylomata. 

Internal  Hemorrhoids  bleed  but  slightly  unless  the  wall  of 
a  large  vein  is  ulcerated  through  or  ruptured.  The  bleeding 
is  usually  venous,  and  started  by  straining  during  stool ;  it 
may  amount  to  only  a  few  drops  and  cease  immediately  after 
stool,  or  it  may  be  profuse  and  continue  for  hours.  In  rare 
instances  the  blood  has  the  appearance  of  being  of  arterial 
origin. 

Prolapse  is  accompanied  by  bleeding  only  in  its  most 
aggravated  forms,  in  which  the  bowel  must  be  frequently  re- 
placed, and  remains  outside  of  the  anus  a  greater  part  of  the 
time,  being  irritated  by  walking  and  exercise. 

(473) 


474  DISEASES  OF  THE  RECTUM  AND  ANUS 

Fissures  rarely  bleed.  When  hemorrhage  does  occur,  it  is 
caused  by  defecation,  is  scant,  of  short  duration,  and  is  seen  as 
streaks  upon  the  feces  or  trickling  down  the  limbs. 

TJlceration  of  whatever  kind  invariably  causes  bleeding, 
which  may  be  slight  or  profuse,  venous  or  arterial,  depending 
upon  the  extent  of  the  disease  and  the  size  of  the  vessels  in- 
volved. In  cases  of  rapidly-spreading  syphilitic,  malignant,  or 
tubercular  ulceration  the  hemorrhage  often  becomes  alarming. 

Stricture  complicated  by  ulceration  always  induces  more 
or  less  bleeding.  The  blood  is  discharged  mixed  with  more  or 
less  pus  and  mucus,  the  whole  having  the  appearance  of  coffee- 
grounds,  especially  when  it  has  been  retained  for  some  time. 

Malignant  Disease  sometimes  invades  the  larger  blood-ves- 
sels of  the  rectum,  resulting  in  dangerous  symptoms  or  death 
from  exsanguination. 

Polyps  do  not  bleed  unless  they  are  large  and  protrude. 

Villous  Growths  are  rare,  but  bleed  freely,  especially  during 
defecation. 

Proctitis  is  accompanied  by  hemorrhage  when  the  disease 
is  far  advanced  and  the  mucosa  is  covered  by  pin-point  ulcers 
or  polypoid  excrescences  which  become  detached,  causing 
more  or  less  bleeding. 

Fecal  Impaction,  when  the  mass  has  been  retained  for  a 
long  time,  may  cause  hemorrhage  as  a  result  of  pressure- 
necrosis  or  laceration  of  the  mucous  membrane  during  expul- 
sion. 

Chancroids  and  Chancres  usually  bleed  but  slightly,  and  are 
very  rarely  attended  by  profuse  hemorrhage. 

Condylomata  involving  the  mucosa  are  very  fragile,  and 
may  be  easily  broken  ofif  by  the  passage  of  feces.  In  such  cases 
the  bleeding  is  slight,  but  apt  to  be  persistent. 

2.  Traumatism  is  not  an  infrequent  cause  of  hemorrhage 
from  the  rectum  or  anus.  It  may  be  the  result  of  a  foreign 
body — e.g.,  fish-bones,  pins,  etc. — which  has  been  swallowed  or 
forced  through  the  anus.  Again,  it  may  follow  gunshot,  stab, 
or  impaling  wounds;    pederasty,  or  external  violence. 

3.  Operations  about  the  rectum  and  anus  are  always  accom- 
panied and  sometimes  followed  by  the  loss  of  more  or  less 
blood.  The  amount  of  hemorrhage  caused  by  an  operation 
depends,  of  course,  upon  the  length,  depth,  and  location  of  the 
incisions  made.    Incisions  made  at  7'ight  angles  to  the  bowel  are 


HEMORRHAGE  475 

accompanied  by  more  bleeding  than  those  made  parallel  with 
the  long  axis,  because  in  the  former  some  of  the  large  hemor- 
rhoidal veins  and  their  branches  are  severed,  while  in  the  latter 
the  incisions  may  be  made  between  these  vessels  and  without 
injury  to  them.  This  accounts  for  the  profuse  hemorrhage  in 
Whitehead's  operation  and  in  operations  for  extensive  prolapse 
and  excision  of  the  rectum;  and  also  for  the  slight  amount  of 
bleeding  attending  internal  proctotomy,  the  division  operation 
for  fissure,  etc. 

Like  those  occurring  in  othef  parts  of  the  body,  hemor- 
rhages induced  by  rectal  operations  may  be  (1)  primary,  (2) 
recurrent,  or  (3)  secondary. 

Primary  hemorrhage  occurs  during  the  operation.  If  it 
occur  from  a  severed  artery  or  vein,  it  is  very  profuse  and 
alarming;  but,  if  from  capillary  oozing,  it  is  less  dangerous,  but 
sometimes  most  annoying  to  the  operator. 

Recurrent  hemorrhage  is  more  serious.  It  occurs  when  a 
vessel  has  been  injured  during  operation  and  does  not  bleed 
at  the  time  or  is  overlooked,  or  it  supervenes  upon  slipping  of 
a  ligature  which  has  been  improperly  tied  or  cut  too  short. 
The  bleeding  takes  place  shortly  or  within  a  few  hours  after 
the  operation. 

Secondary  hemorrhage  occurs  several  days  after  the  opera- 
tion, usually  from  the  fifth  to  the  eighth  day,  as  a  result  of 
failure  of  a  vessel  to  become  occluded  by  an  organized  throm- 
bus as  the  ligature  cuts  its  way  out.  Again,  it  may  follow 
sloughing  or  ulceration  due  to  burning,  pressure-necrosis,  or 
other  causes.  Secondary  hemorrhage  occurs  more  frequently 
in  anemic  and  debilitated  patients  and  in  those  who  have  a 
cough  or  other  complication  inducing  straining  or  tenesmus 
than  in  robust  persons.  As  a  rule,  the  bleeding  comes  on  sud- 
denly and  is  very  profuse,  and  unless  arrested  immediately  may 
prove  fatal.  After  rectal  operations  the  nurse  should  be  in- 
structed to  be  on  the  alert  for  hemorrhage,  since  the  bleeding 
may  be  internal  and  fatal  while  not  the  slightest  amount  of  blood 
escapes  from  the  anus. 

SYMPTOMS   AND   DIAGNOSIS 

The  symptoms  of  hemorrhage  from  the  rectum  and  anus, 
whether  caused  by  disease,  traumatism,  or  operations,  are  the 
same.      Slight  hemorrhage,  except  as  a  symptom  of  disease,  is 


476  DISEASES  Ui^'  THE  RECTUM  AND  ANUS 

of  little  importance,  because  it  can  be  quickly  and  easily- 
arrested  by  the  application  of  pressure  or  styptic  and  astrin- 
gent remedies. 

Profuse  heniorrhage  is  always  accompanied  by  alarming 
and  well-marked  symptoms.  Usually  the  first  external  evi- 
dence of  bleeding  is  a  gush  of  pure  blood  from  the  rectum. 
When  dressings  have  been  firmly  applied,  the  gauze,  cotton, 
bandages,  and  even  the  bed  may  quickly  become  saturated 
with  blood  and  on  removal  of  the  dressings  blood  will  be  seen 
trickhng  through  the  anus  in  a  small  stream.  Again,  the  hem- 
orrhage may  be  concealed.  Without  warning,  large  quantities 
of  blood  may  collect  in  the  rectum  and  become  clotted,  causing 
a  desire  to  go  to  the  stool  at  short  intervals;  the  evacuations 
then  consist  of  liquid  or  clotted  blood,  or  when  the  blood 
has  been  retained  for  some  time  the  stools  assume  the  charac- 
teristic "coffee-ground"  appearance  and  have  a  foul  odor. 
This  is  one  of  the  first  and  most  important  symptoms  of  dangerous 
hemorrhage.  The  next  most  frequent  symptoms  of  concealed 
hemorrhage  are  colicky  pains  and  tympanites  along  the  course 
of  the  colon,  due  to  decomposition  of  retained  blood  and  con- 
sequent formation  of  gases ;  the  longer  the  blood  is  retained  in 
the  bowel,  the  more  intense  do  these  symptoms  become.  An- 
other sign  of  concealed  hemorrhage  is  frequent  desire  to  mic- 
turate, with  inability  to  evacuate  the  bladder,  probably  owing  to 
irritation  of  the  levator  ani  muscle  by  the  distension  of  the 
bowel.  If  the  hemorrhage  is  not  discovered  and  arrested  at 
this  time,  but  continues  until  exsanguination  is  almost  com- 
plete, the  patient  has  a  death-Hke  pallor,  becomes  anxious,  rest- 
less, faint,  and  finally  unconscious ;  the  pulse-rate  increases, 
but  the  beat  loses  in  force  and  volume  and  gradually  becomes 
imperceptible ;  finally  the  patient  collapses  and  dies  of  com- 
plete exsanguination.    ■ 

METHODS   OF   ARRESTING   HEMORRHAGE 

The  methods  of  arresting  hemorrhage  are  many,  but  those 
found  to  be  most  reliable  are : — 

1.  Ligation.  ,      4.  Application    of    hot    or 

2.  Pressure.  cold  water. 

3.  Torsion  and  clamping.  5.   Cauterization. 

6.  Styptics. 


HEMORRHAGE  477 

Ligation  is  always  to  be  relied  upon  when  large,  spurting 
vessels  have  been  ruptured  by  disease  or  severed  during  opera- 
tion. Catgut  or  silk  Hgatures  are  the  best  for  this  purpose. 
The  vessel  should  be  firmly  grasped  with  artery-forceps  and 
the  ligature  applied  well  beyond  the  end  of  the  clamp,  in  order 
to  obtain  a  good  hold ;  then  two,  or,  better,  three,  knots  should 
be  tied  and  the  ends  of  the  ligature  left  long  to  prevent  sHp- 
ping.     Masses  of  tissue  which  bleed  from  a  number  of  points 


Fig.  160. — Drainage-tube  Wrapped  with  Gauze. 

may  also  be  ligated  if  desirable ;  the  ligature  should  be  firmly 
applied  about  their  base  or  by  a  double  ligature,  as  the  bleeding 
may  be  averted  by  a  running  suture. 

Pressure  may  be  used  to  arrest  capillary  oozing  or  bleeding 
from  a  small  vessel.  In  conjunction  with  hot  water  it  is  espe- 
cially useful  during  operations.  Superficial  compression  is  not 
to  be  relied  upon  in  extensive  wounds  in  which  large  vessels 
have  been  injured  and  cannot  be  reached  or  located  for  liga- 
tion.    In  such  cases  the  wound  should  be  tightly  packed  with 


Fig.  161. — Hollow  Vulcanite  Draining-tube. 


Strips  of  dry  sterile  or  antiseptic  gauze.  This  dressing  should 
be  further  supported  with  external  pressure.  When  the  pa- 
tient's Hfe  is  jeopardized  by  profuse  hemorrhage  in  the  rectum, 
the  result  of  either  disease  or  operation,  and  the  bleeding  ves- 
sels cannot  be  exposed  and  ligated  after  everting  the  anus  or 
use  of  the  speculum,  time  should  not  be  wasted  in  experiment- 
ing, but  some  form  of  pressure  should  immediately  be  applied. 
This  can  sometimes  be  done  speedily  by  inserting  into  the  rec- 
tum a  piece  of  firm,  rubber  tubing,  three  inches  (Y.62  centi- 


478 


DISEASES  OF  THE  RECTUM  AND  ANUS 


meters)  long  and  three-fourths  of  an  inch  (0.635  centimeter) 
in  diameter,  around  which  has  been  wrapped  several  layers  of 
gauze  (Fig.  160).  This  can  be  kept  in  place  by  attaching 
the  outer  end  to  a  T-bandage  by  means  of  a  safety-pin.  This 
contrivance  makes  suitable  pressure  and  at  the  same  time 
allows  gas,  discharges,  and  blood  to  escape,  the  latter  giving 
warning  in  case  the  hemorrhage  has  not  been  arrested.  Hol- 
low vulcanite  tubes  have  also  been  devised  for  this  purpose 
(Fig.  161).  Another  admirable  device  for  arresting  hemor- 
rhage is  the  India-rubber  tampon  devised  by  Mr.  Benton  and 
modified  by  Mr.  Swinford  Edwards  (Fig.  162). 

A  better  method  than  either  of  the  foregoing  is  to  pack 
the  rectum  thoroughly  with  gauze.  In  a  few  cases  in  which 
the  patient  was  too  far  gone  or  refused  to  take  an  anesthetic, 


Fig.  162.— Benton's  India-Rubber  Tampon  (Modified  by  Edwards). 


the  author  has  succeeded  in  controlling  the  hemori-hage  by  in- 
serting the  author's  modification  of  the  Darmack  gauze-carrier 
well  up  the  bowel  and  packing  the  rectum  from  above  down- 
ward (Fig.  163).  This  operation  when  carefully  performed 
causes  the  patient  but  little  pain.  The  author's  favorite  method 
of  packing  the  rectum,  which  is  more  reliable  and  quicker,  is 
as  follows:  Take  a  three-inch  (7.62  centimeters)  gauze  band- 
age, five  yards  (4.5  meters)  in  length  and,  working  with  the 
index  fingers  in  a  hand-over-hand  fashion,  rapidly  pack  the 
upper  rectum,  leaving  the  folded  ends  of  the  bandage  hang- 
ing out  of  the  anus ;  the  operation  is  to  be  repeated  with 
bandages  until  the  rectum  is  tightly  packed  down  to  the  anus; 
the  'ends  of  the  bandages  should  be  carefully  arranged  in  order 
external  to  the   anus,   so   that  they  may  be   successfully  with- 


HEMORRHAGE 


479 


drawn  when  the  packing  is  removed.  A  thick,  wedge-shaped 
compress  of  gauze  is  then  placed  over  the  anus  and  held  with 
firm  pressure  by  a  well-adjusted  T-bandage. 

Another  way  to  pack  the  rectum  well  and  quickly  is  to 
take  four  thicknesses  of  cheese-cloth,  a  yard  (91.4  centimeters) 
square,  and  cut  a  small  hole  in  the  center;  through  this  hole 
pass  a  No.  10  Wales  bougie  and  tie  the  cloth  around  it  about 
two  inches  (5.08  centimeters)  from  the  pointed  end;  introduce 
the  bougie  into  the  rectum  to  the  desired  height  and  pack  strips 
of  gauze  into  the  space  between  the  bougie  and  cloth  until  the 
pressure  is  sufficient  to  arrest  the  hemorrhage.    The  cloth,  still 


^tD'v^- 


Fig.  163.- 


-Method  of  Packing  the  Rectum  with    Gant's  Modification 
of  the  Darmack  Gauze-carrier. 


remaining  outside  the  anus,  is  to  be  gathered  around  the  l^ougie 
in  the  form  of  a  compress,  which  is  supported  by  a  T-bandage 
having  a  hole  cut  through  it  for  the  bougie.  One  advantage 
of  this  packing  is  that  flatus  and  feces  may  escape  through  the 
bougie,  adding  much  to  the  comfort  of  the  patient. 

Mr.  Allingham  packs  the  rectum  after  the  following  man- 
ner :  A  strong  Hgature  is  passed  through  a  cone-shaped  sponge 
near  the  apex.  The  ligature  is  then  brought  back  again 
through  the  sponge  so  that  the  apex  is  held  in  a  loop;  the 
sponge  is  dampened  and  dusted  over  with  some  astringent — 
preferably    iron — and    squeezed    dry.      Guided    by    the    index 


480  DISEASES  OF  THE  RECTUM  AND  ANUS 

finger,  the  sponge  is  introduced  into  the  rectum,  apex  first, 
and  carried  up  five  inches  (12.70  centimeters),  leaving  the  ends 
of  the  hgature  outside  the  anus.  The  portion  of  the  rectum 
below  the  sponge  is  packed  with  cotton  dusted  over  with  as- 
tringent powder.  When  this  is  completed  the  hgature  is 
grasped  and  the  sponge  pulled  downward  with  one  hand  and 
the  cotton  pushed  up  with  the  other ;  in  this  way  the  sponge  is 
made  to  spread  out  and  the  cotton  is  compressed  tightly  at  the 
same  time.  If  this  be  carefully  done,  Allingham  asserts  that  it 
is  impossible  for  bleeding  to  occur  either  internally  or  exter- 
nally. The  author  has  frequently  resorted  to  this  procedure, 
but  finds  it  more  effective  when  the  ligatures  are  tied  over 
an  external  compress. 

Torsion  and  Clamping  are  sometimes  of  service  in  arresting 
hemorrhage.  In  the  former  the  vessel  is  seized  and  twisted 
with  an  artery-forceps  and  then  released ;  in  the  latter  the  ves- 
sels are  caught  with  a  long-handled  forceps,  which  is  allowed 
to  remain  in  place,  projecting  from  the  rectum,  until  all  danger 
of  further  hemorrhage  has  passed.  Simple  torsion  of  a  large 
bleeding  vessel  is  unsafe.  Clamping  is  useful  and  indicated 
when  the  bleeding  vessel  is  too  high  up  to  be  ligated,  and  may 
also  be  used  to  arrest  persistent  hemorrhage  from  several 
points  close  together,  by  clamping  the  tissue  en  masse. 

Ice-  or  Hot  Water  frequently  proves  of  value  as  a  hemo- 
static. Capillary  oozing  can  be  stopped  almost  instantly  by 
pressing  upon  the  bleeding  surface  with  cotton  or  a  sponge 
dipped  in  water  at  a  temperature  of  115°  to  120°  F.  (46°  to 
48°  C).  Ice-cold  water  is  less  reliable,  but,  when  applied  to  the 
rectum  and  over  the  sacrum  and  coccyx,  oozing  is  frequently 
diminished  and  sometimes  arrested. 

Cauterization  may  be  made  with  either  chemic  agents  or 
the  Paquelin  cautery-point,  the  latter  being  the  more  reliable. 
In  the  absence  of  these,  a  red-hot  iron,  such  as  a  poker-  or 
curling-  iron,  may  be  used.  The  actual  cautery  may  be  rehed 
upon  to  control  capillary  oozing  or  hemorrhage  from  small 
vessels,  but  should  not  be  employed  to  close  large  vessels  ex- 
cept where  the  tissues  including  the  vessels  are  clamped  to  stop 
the  bleeding  and  the  cautery,  heated  to  a  dull  red,  is  thoroughly 
applied  as  in  hemorrhoidal  operations. 

Styptics  and  Astringent  agents  may  be  used  to  arrest  oozing, 
but  are  never  to  be  employed  to  stop  bleeding  from  a  spurting 


HEMORRHAGE  481 

vessel.  The  following  drugs,  either  in  solution  or  as  dusting- 
powders,  have  been  employed  for  this  purpose :  Monsell's  pow- 
der, extract  of  suprarenal  capsule,  gallic  and  tannic  acids,  zinc 
sulphate,  copper  sulphate,  lead  acetate,  hydrogen  peroxide,  and 
acetic  acid  (vinegar).  Of  these  the  most  reliable  are  extract  of 
suprarenal  capsule,  hydrogen  peroxide,  vinegar,  and  Monsell's 
powder.  The  latter  is  objectional  because  it  leaves  the  wound 
and  parts  in  a  filthy  condition.  Vinegar  is  obtainable  in  any 
home,  and  may  be  used  pure  or  combined  with  three  parts  of 
water  as  an  irrigating  agent  or  upon  gauze  as  a  packing  for 
deep  wounds.  The  apphcation  of  suprarenal  capsule  imme- 
diately constricts  the  vessels.  It  is  especially  serviceable  in 
arresting  bleeding  from  superficial  erosions,  and  when  the  parts 
are  extremely  sensitive  it  may,  with  advantage,  be  combined 


Fig.  164.— Gant's  Rectal  Evacuator. 

with  eucaine  or  chloretone,  which  is  a  local  anesthetic.  Hydro- 
gen peroxide,  in  addition  to  being  an  antiseptic,  is  especially 
useful  to  arrest  oozing  during  operations. 

General  Treatment  of  Hemorrhage.  —  In  cases  in  which  de- 
pletion has  been  so  great  as  to  endanger  the  patient's  life,  every 
effort  should  be  made  to  improve  his  condition  and  prevent  a 
recurrence.  If  necessary,  the  blood-column  should  be  in- 
creased by  transfusing  a  sufficient  quantity  of  physiologic  salt 
solution,  or  by  the  injection  of  6  to  8  ounces  of  the  same  beneath 
the  skin.  Hot-water  bottles  should  be  placed  around  the 
patient  and  the  heart  stimulated  with  strychnine  or  brandy 
either  by  mouth  or  hypodermic  injection.  He  should  be  kept 
quiet  in  the  recumbent  position,  with  the  hips  elevated,  and 
restricted  to   a  liquid  diet.      The   intestines  should  be  kept  in- 


482  DISEASES  OF  THE  RECTUM  AND  ANUS 

active  with  hypodermic  injections  of  morphine  or  enemata  con- 
taining V2  drachm  (2  grams)  of  laudanum  or  2  grains  (0.13 
gram)  of  the  extract  of  opium.  In  cases  in  which  there  is  some 
doubt  as  to  the  location  of  the  bleeding-point  in  the  intestine, 
the  internal  administration  of  iron  perchloride,  tannic  or  gallic 
acid,  and  other  astringent  remedies,  or  ergot  or  ergotine  in 
liberal  doses,  is  justifiable. 

In  conclusion,  the  writer  would  emphasize  the  importance 
of  instructing  the  nurse  after  rectal  operations,  no  matter  how 
trivial,  to  be  constantly  on  the  lookout  for  bleeding  and  to 
keep  the  bandage  tightly  adjusted.  Sometimes  both  patient 
and  nurse  are  unnecessarily  alarmed  because  the  dressings  be- 
come saturated  with  a  red  fluid,  which,  on  close  examination, 
proves  to  be  the  irrigating  fluid,  stained  with  blood,  which  had 
not  been  removed  from  the  bowel  before  the  dressings  were 
appHed.  In  order  to  avoid  this  accident  it  has  been  the  custom 
of  the  writer  to  empty  the  rectum,  after  an  operation,  with 
the  Gant  rectal  evacuator  (Fig.  164). 


CHAPTER  XXXI 

NON=MALIQNANT  TUMORS  (RECTAL  POLYPS) 

The  term  polyp  is  commonly  applied  to  any  outgrowth 
in  the  rectum  having  a  narrow,  pedunculated  attachment  and 
a  large,  pendulous  extremity.  Owing  to  straining  during  defe- 
cation and  the  constant  downward  force  exerted  by  the  feces 
and  peristalsis,  benign  tumors  of  whatever  kind  occurring  in  the 
rectum  usually  become  pedunculated  in  time,  and  the  pedicle 
gradually  increases  in  length.  For  this  reason,  authors  often 
describe  non-malignant  tumors  of  the  rectum  under  the  title.: 
"Rectal  Polyps." 

The  ano-rectal  region  is  not  uncommonly  the  site  of  be- 
nign outgrowths ;  in  fact,  such  tumors  occur  in  this  region  far 
more  frequently  than  is  generally  supposed.  They  may  occur 
in  any  climate,  in  the  robust  or  delicate  in  either  sex  and  at 
any  age,  but  are  more  common  to  women  and  children.  In 
90  cases  treated  by  Bodenhamer  the  ages  of  the  patients  ranged 
from  3  to  75  years;  15  were  children  under  5  years;  45  were 
adult  females  and  30  were  adult  males. 

Polypoid  tumors  may  be  single  or  multiple,  large  or  small, 
smooth  or  rugg-ed,  and  globular  or  elongated  in  form.  In  con- 
sistence they  may  be  soft  or  hard,  friable  or  tough.  They  may 
occur  in  any  part  of  the  intestine,  but  are  most  frequent  in  the 
rectum.  Leichtenstern  gives  the  relative  frequency  of  polyps 
in  the  various  parts  of  the  intestine  as  follows :  In  the  duo- 
denum, 2  ;  jejunum,  5  ;  ileum,  30  ;  ileo-cecal  valve,  2  ;  cecum, 
4;  colon,  10;  rectum,  75.  Polyps  are  usually  attached  by  a 
single  stem,  though  in  very  rare  instances  they  may  have  two, 
three,  or  more  attachments.  Bodenhamer  reports  three  cases 
in  which  the  attachments  were  multiple.  In  most  cases  they 
are  the  color  of  the  normal  mucous  membrane,  though  they 
may  be  pale  or  somewhat  purple. 

The  following  tumors  are  encountered  about  the  rec- 
tum and  anus  with  varying  frequency,  most  of  them  within  the 
rectum,  in  the  form  of  polyps : — 

(483) 


484  DISEASES  OF  THE  RECTUM  AND  ANUS 


1. 

2. 
3. 

Adenoma. 

Lipoma. 

Fibroma. 

7.  Cystoma. 

8.  Myoma. 

9.  Enchondroma, 

4. 

5. 

Papilloma. 
Angioma. 

10.  Myxoma. 

11.  Spina  bifida. 

6. 

Teratoma. 

12.   Osteoma. 

13. 

Eleph: 

antiasis. 

Coccygeal  tumors  and  hemorrhoids  are  fully  discussed  in 
other  chapters,  and  will  not  be  considered  here. 

Adenoma  (Glandular  Polyp).  —  Adenomata  are  polypoid- 
like,  hypertrophied  glandular  tumors  composed  of  glandular 
tissue  (Plates  XXVII  and  XXVIII).  They  constitute  the 
major  portion  of  the  benign  outgrowths  occurring  in  the  intes- 
tinal tract,  and  are  encountered  in  the  rectum  far  more  fre- 
quently than  in  all  other  parts  of  the  small  or  large  intestine. 
Simple  adenomata  are  most  common  in  childhood,  and  are 
comparatively  rare  in  adult  Hfe  except  when  antedated  by  some 
other  disease  accompanied  by  a  discharge  which  constantly  irri- 
tates the  mucosa.  On  the  other  hand,  mahgnant  adenomata 
occur  most  often  in  those  past  middle  life,  and  are  rarely  seen  in 
children.  Adenomatous  polyps  may  be  single,  multiple  and  dis- 
seminated, large  or  small,  smooth  or  ragged,  and  occur  in  any 
part  of  the  rectum.  They  are  most  often  located  at  the  junction 
of  the  fixed  and  movable  rectum,  though  the  writer  has  re- 
moved them  from  just  within  the  anus. 

The  etiology  of  rectal  adenomata  is  not  clearly  understood, 
but  there  is  every  reason  to  believe  that  they  may  be  secondary 
to  mechanic  irritation  or  inflammatory,  ulcerative,  or  infective 
processes.  The  author  has  treated  numerous  cases  of  rectal 
polyps,  and  in  many  there  were  no  evidences  of  other  intestinal 
disease.  In  the  majority,  however,  a  diseased  condition  of  the 
bowel,  accompanied  by  an  acrid  discharge,  existed,  which  con- 
stantly irritated  the  mucosa. 

The  author  has  several  times  removed  rectal  adenoids  in 
children  who  had  been  previously  operated  upon  for  similar 
growths  located  in  the  naso-phar3mx,  and  it  would  appear  that 
in  some  cases  there  is  a  common  cause  which  results  in  the 
formation  of  these  tumors  in  the  lymphoid  structures  of  both 
the  naso-pharynx  and  rectum.  This  point  has  been  emphasized 
by  Dr.  Francis  Huber,  of  New  York,  who  says : — 


EXPLANATION  OF  PLATE  XXYII 


Photograph  of  an  entire  section. 

Above  is  a  highly  complicated  adenomatous  growth 
which  does  not  at  any  point  break  through  the  muscu- 
laris  mucosae.  The  three  dark  patches  below  the  ad- 
enoma are  hyperplastic  solitary  lymph-follicles,  or  posvsi- 
bly  the  fused  follicles  of  a  Peyer  patch. 

On  the  left  the  adenomatous  growth  gradually  de- 
creases and  shades  off  into  the  normal  mucous  membrane 
below.  At  the  lowest  part  of  the  section  is  a  normal 
Peyer  patch,  consisting  of  oval  lymph-nodes. 

The  mnscnlaris  mucosae  can  be  traced  as  a  thin  line 
underlying  the  mucous  membrane,  although  it  can 
hardly  be  seen  at  the  upper  part,  where  the  adenomatous 
growth  is  thickest.  Under  the  microscope,  however,  it 
can  be  resolved  and  shown  to  be  still  intact,  although 
the  pressure  of  the  overlying  growth  has  thinned  it  out 
and  caused  some  irregularity  in  its  arrangement.  The 
tumor,  therefore,  shows  no  tendency  toward  infiltra- 
tion of  the  neighboring  tissues,  and  is  to  be  considered 
as  of  a  benign  nature,  although  such  growths  are  liable 
at  any  time  to  develop  malignancy. 

The  submucous  tissue  appears  as  a  pale  layer  con- 
taining numerous  blood-vessels,  and  to  the  right  of  this 
are  the  muscular  layers,  somewhat  torn  in  preparing  the 
specimen. 


FLUTE  XXmi 


% 


'.*^"':^-^- 


UdE-nama  of  the  Rsctum,     [Magnificatian,  B,] 


NON-MALIGNx'^NT  TUMORS  485 

"I  have  noticed  one  feature  common  to  all  the  cases :  rectal 
polypi  were  only  found  in  patients  zvho  at  the  same  time  showed 
evidences  of  lymphoid  hypertrophies  in  the  naso-pharynx  with 
other  manifestations  of  the  constitutio  lymphaticns,  status  lym- 
phaticus.  This  can  hardly  be  a  mere  coincidence.  On  the  con- 
trary, the  observations,  made  in  my  own  cases,  and  in  those  in 
the  practice  of  professional  friends,  have  led  me  to  believe  that 
the  variety  of  rectal  polyps  under  discussion  is  simply  a  local 
manifestation  of  the  status  lymphaticns." 

The  first  changes  noticeable  in  the  incipiency  of  an  ade- 
nomatous growth  occur  in  the  crypts  of  Lieberkiihn,  which  are 
not  only  increased  in  number,  length,  and  size,  but  the  cylin- 
dric  epithelial  cells  Hning  them  become  increased  in  number 
and  size.  There  is  an  increased  formation  of  delicate  con- 
nective tissue  (Plate  XXVII).  At  a  later  period  the  tubular 
glands  are  numerous,  enlarged,  misshapen,  coiled,  branching, 
and  usually  grouped.  The  epithelial  cells  lining  the  tubules  are 
altered,  and,  in  contradistinction  to  cylindric-celled  epithe- 
lioma have  but  a  single  nucleus,  which  may  be  atrophied,  and, 
if  so,  some  writers  say  that  vegetations  or  superimposed  cells 
may  be  seen  within  the  gland-duct.  After  the  newly-formed 
tubules  become  enlarged  or  cystic  the  epithelium  may  be 
absent;  but,  if  present,  the  cells  are  of  the  flattened  or  cuboid 
variety.  The  mucous  membrane  is  thickened  and  more  irregu- 
lar than  normal.  There  is  an  increased  amount  of  connective 
tissue,  which  is  not  dense,  but  contains  many  lymph-corpuscles 
and  leucocytes  in  its  meshes  (adenoid  tissue).  According  to 
Quenu  and  Hartmann,  the  proliferation  may  be  by  segmenta- 
tion, external  budding,  or  intratubular.  The  adenomatous  out- 
growth can  now  be  seen  as  an  ovoid  tumor  projecting  into  the 
lumen  of  the  bowel.  The  pedicle  is  seen  at  a  later  period : 
short  and  thick  at  first,  but  increasing  until  it  is  an  inch  (2.54 
centimeters)  or  more  in  length,  and  becoming  more  slender  in 
proportion  to  the  size  of  the  tumor.  The  mucous  membrane 
covering  the  tumor  and  its  pedicle  is  continuous  with  that  of 
the  rectum ;  owing  to  the  irritation  of  the  feces,  however,  it  is 
more  highly  colored,  and  may  become  ulcerated.  The  gland- 
ular changes  are  now  much  more  marked  especially  at  the 
periphery.  The  tumor  assumes  the  typic  pear  or  bell-clapper 
shape,  and  is  usually  ragged,  soft,  and  fragile ;  but,  if  the  con- 
nective-tissue element  is  marked  and  dense,  the  growth  is  firm 


486  DISEASES  OF  THE  RECTUM  AND  ANUS 

and  smooth  or  nodular.  The  blood-supply  of  the  growth  is 
ample.  Both  the  efferent  and  afferent  vessels  are  small  and 
pass  through  the  pedicle,  where  the  pulsations  of  the  artery  can 
sometimes  be  felt. 

In  rare  instances  adenomata  varying  from  the  size  of  a 
millet-seed  to  that  of  a  walnut  may  occur  in  great  numbers  in 
the  rectum  and  extend  upward  throughout  the  colon.  This 
condition  has  been  designated  disseminated  polyps,  polyadenoma, 
or  polyposis.  This  condition  is  more  grave  because  of  the  dif- 
ficulty of  removing  the  growths,  their  tendency  to  return  after 
removal,  the  danger  of  obstruction,  and  the  frequency  with 
which  they  are  transformed  into  cylindric-celled  epithelioma. 
They  are  usually  secondary  to  dysentery,  chronic  diarrhea, 
chronic  proctitis,  syphilitic  ulceration,  rectal  prolapse,  and,  in 
fact,  anything  which  causes  constant  and  prolonged  irritation 
to  the  mucosa.  The  author  recently  saw  two  cases  of  dissemi- 
nated polyps,  neither  of  which  degenerated  into  cancer;  one 
was  the  result  of  chronic  hypertrophic  proctitis  and  the  other 
was  attributed  to  secondary  syphilitic  ulceration.  In  both  cases 
the  polyps  were  multitudinous,  of  various  sizes  and  shapes,  and 
scattered  in  every  part  of  the  rectum,  sigmoid  flexure,  and  up 
the  bowel  farther  than  could  be  determined  through  the  long 
colonoscope.  The  author  was  unable  to  relieve  permanently 
either  of  these  patients,  for  the  reason  that  the  growths  re- 
turned within  a  short  time  after  their  removal ;  in  one  case  it 
was  necessary  to  perform  left  inguinal  colostomy  in  order  to 
relieve  the  obstruction. 

The  changes  which  take  place  in  the  glandular  structures 
in  cases  of  polyadenoma  are,  in  the  main,  similar  to  those  which 
occur  in  simple  adenoma.  Quenu  and  Hartmann  have  found 
that  there  is  more  uniformity  of  the  tubules,  the  epithelium  is 
composed  almost  entirely  of  goblet-cells  (Plate  XXVIII),  while 
the  mucous  membrane  may  be  atrophied,  the  glands  almost 
completely  destroyed,  and  the  blood-supply  abundant.  The 
same  authorities,  who  have  made  an  exhaustive  study  of  this 
subject,  assert  that  malignant  degeneration  occurs  in  about  one- 
half  of  the  cases,  the  cancer  being  in  most  instances  cylindric- 
celled  epithelioma,  and  that  the  cancerous  transformation  is 
usually  antedated  several  years  by  polyposis.  Contrary  to  this, 
Hauser  reports  that  in  polyadenoma  he  was  unable  to  find 
goblet-cells,  but  cells  which  were  similar  in  character  to  those 


EXPLANATION  OF  PLATE  XXVIII 


The  alveoli,  containing  raucous  and  granular  detritus, 
are  lined  by  columnar  epithelial  cells,  the  nuclei  of  which 
are  deeply  stained  and  somewhat  elongated.  Many  of 
the  cells  are  distended  with  mucus,  forming  the  so-called 
goblet  cells. 

The  cells  rest  on  a  basement  membrane,  which,  how- 
ever, cannot  be  clearly  recognized  in  the  photograph,  and 
the  supporting  connective  tissue  is  highly  cellular,  but 
not  more  so  than  normally  in  the  intestinal  mucous 
membrane. 


PLMTE  XXUin 


Rdenama  of  ths  RBctum,     [Magnification,  25D,] 


NON-MALIGNANT  TUMORS  487 

of  cylindric-celled  epithelioma;  furthermore,  the  mucosa  was 
hypertrophied. 

Adenoma  distohiensis  is  a  form  of  adenomata  made  up  of 
glandular  and  granulation  tissue  and  caused  by  the  irritation 
induced  by  the  ova  of  the  distoina  hmnatobium.  This  parasite 
is  common  in  Egypt.  The  mature  worms  inhabit  the  trunk  and 
branches  of  the  portal  vein  and  the  venous  plexuses  of  the 
urinary  bladder  and  rectum.  It  is  deposited  in  the  small  veins 
and  tissues  of  the  intestine,  where  it  acts  as  a  source  of  irri- 
tation. Polyps  of  this  variety  are  common  to  Egypt,  and  were 
first  described,  in  1885,  by  Belleli,  an  Egyptian  physician,  who 
further  reports  that  they  may  be  multiple  and  occur  in  suf- 
ficient numbers  to  cause  obstruction. 

Lipoma. : —  Lipomata  are  tumors  composed  principally  of 
adipose  tissue  (fat).  These  growths  occasionally  occur  in  the 
perirectal  tissues,  in  the  rectum,  and  in  the  buttocks  about  the 
anus,  their  favorite  site  being  in  the  upper  rectum.  They 
do  not  differ  from  fatty  tumors  in  other  parts  of  the  body, 
except  that,  when  located  in  the  upper  rectum,  they  may  con- 
tain a  fold  of  peritoneum.  It  has  been  suggested  that  they  may 
be  inverted  appendices  epiploicse  which  have  descended;  but 
there  is  little  evidence  to  sustain  this  theory.  In  the  rectum 
they  may  originate  in  the  submucous  coat  and  soon  become 
pedunculated.  They  are  characterized  by  an  unusually  long 
pedicle.  They  are  dark  brown  in  color,  and  may  be  quite  small 
or  assume  large  proportions. 

Some  years  ago.  Wells  presented  before  the  London 
Pathologic  Society  a  specimen  of  lipoma  weighing  two  pounds 
which  he  had  removed  from  the  rectum  and  adjacent  struct- 
ures. Bodenhamer  reports  the  case  of  a  negro  woman  from 
whose  rectum  he  removed  a  lipoma  as  large  as  a  hen's  o-gg. 
Many  other  cases  of  lipomata  have  been  reported  by  Bernard, 
Rose,  Virchow,  Esmarch,  Voss,  and  others.  The  author  has 
treated  but  four  cases  of  lipoma  in  the  ano-rectal  region.  In 
one  case  the  tumor  removed  was  about  as  large  as  a  walnut, 
and  was  attached,  four  inches  (10.6  centimeters)  above  the 
anus,  to  the  left  lateral  wall  of  the  rectum  by  a  pedicle  about 
one  inch  (2.54  centimeters)  long.  In  the  other  three  the  tu- 
mors were  external  to  the  bowel:  one  was  about  the  size  of 
a  cherry  and  located  in  the  perineum  in  front  of  the  anus ;  the 
second  was  situated  on  the  left  buttocks  at  the  verge  of  the 


488  DISEASES  OF  THE  RECTUM  AND  ANUS 

anus,  and  was  almost  as  large  as  an  egg;  the  third  was  on 
the  right  buttock,  its  nearest  point  being  about  one  inch  (2.54 
centimeters)  from  the  anus,  and  was  flat,  oval,  and  quite  large, 
and  when  removed  weighed  a  pound  and  a  half  (680  grams). 

In  some  cases  fibrous  tissue  may  be  a  prominent  element 
in  the  make-up  of  a  lipoma;  the  tumor  is  then  designated  as 
fibrolipoma. 

Fibroma. — Not  infrequently  fibromata  develop  in  the  rec- 
tum or  ano-vulvar  region.  These  tumors  are  composed  of 
connective  tissue,  and,  as  compared  with  adenomata,  are  very 
dense.  In  the  rectum  they  originate  in  the  submucous  tissue 
and  become  pedunculated ;  when  found  upon  the  surface  about 
the  anus,  they  present  as  hard,  glistening,  ovoid  tumors  having 
a  broad  base.  When  in  the  rectum  they  are  pale  in  color, 
nodular,  and  very  firm ;  both  stem  and  tumor,  when  grasped 
between  the  fingers,  feel  very  much  like  a  piece  of  gristle.  In 
rare  instances  fibromata  occurring  in  this  region  have  been 
found  to  be  cavernous.  Bowlby  has  recorded  a  most  remark- 
able case  of  fibroma  of  the  rectum  in  which  the  tumor  was  the 
size  of  a  fetal  head  and  was  attached  to  the  anterior  rectal  wall, 
about  four  inches  (10.6  centimeters)  up,  by  a  pedicle  one  and 
a  half  inches  (3.71  centimeters)  broad ;  the  tumor  when  removed 
weighed  two  pounds  lacking  one  ounce  (800  grams),  and  was 
found  to  be  made  up  of  loose  connective  tissue  inclosing  in  its 
meshes  a  viscid  substance.  The  author  has  several  times  re- 
moved from  the  rectum  polypoid  tumors  which,  from  all  clinic 
appearances,  were  fibromata.  He  has  treated  but  one  case  of 
fibromata  of  the  ano-vulvar  region ;  in  this  case  a  number  of 
hard,  rounded  tumors,  varying  from  the  size  of  a  cherry  to  that 
of  an  egg  (Fig.  165),  almost  completely  concealed  the  vulva 
and  anus ;  they  had  existed  for  a  number  of  years,  and  when 
removed  microscopic  sections  showed  them  to  be  composed 
entirely  of  dense,  fibrous  tissue. 

Papilloma. — Papillomata  are  encountered  quite  frequently 
in  the  ano-rectal  region,  and  occur  on  the  skin  about  the  anus 
as  often  as  upon  the  mucous  membrane.  They  are  usually 
induced  by  irritating  discharges  from  the  rectum  or  vagina, 
although  they  sometimes  appear  when  there  is  no  evidence  of 
such  irritation.  Senn  has  frequently  observed  the  parts  studded 
with  such  tumors,  varying  from  the  size  of  a  hemp-seed  to 
that  of  a  cherry.     When  located  upon  the  mucous  membrane 


NON-MALIGNANT  TUIMORS 


489 


of  the  rectum  they  are  covered  with  cyUndric  epitheHiim ;  when 
situated  upon  the  skin  of  the  anal  region  they  are  covered  with 
squaijious  epitliehnm.  These  tumors  at  times  assume  large 
proportions,  sometimes  causing  complete  obstruction;  they 
may  be  sessile  or  attached  by  a  narrow  or  broad  pedicle. 
They  are  soft  and  spongy  in  consistence,  tender,  bleed  fre- 
quently and  profusely  from  slight  causes,  and  excite  the  dis- 
charge of  considerable  mucus. 

These  papillomatous  growths  resemble  villous  tumors  of 
the  bladder.  Dennis  says :  "Such  growths  spring  from  the 
submucous  connective-tissue  layer;  the  confluent  villi  con- 
sist of  an  axis  of  fibrous  tissue  containing  blood-vessels,  and 


Fig.  165.— Pen  Sketch  of.Ano-Tulvar  Fibromata  (Author's  Case). 


are  covered  by  cylindric  epithelium.  They  present  also  a  cer- 
tain proportion  of  hypertrophied  glandular  follicles.  The 
blood-vessels  are  relatively  large  and  numerous.  Multiple 
delicate  villi  may  compose  the  growth,  giving  its  surface  a 
smooth,  velvety  feel;  or  secondary  knobbed  processes  may 
develop,  producing  a  caulifiower-like  surface.  By  obstruction 
to  the  venous  return  in  the  narrowing  pedicle  edema  and 
cystic  degeneration  of  the  tufts  may  ultimately  develop.  Clin- 
ically they  occupy  a  position  between  adenomata  and  carci- 
nomata,  and,  in  cases  that  have  been  neglected  or  in  which 
sufficiently  wide  extirpation  of  sound  tissue  at  their  base  has 
not  been  made,  the  later  development  of  carcinoma  is  not  in- 
frequent."    Van  Buren  says :    "After  ulceration  and  destruc- 


490 


DISEASES  OF  THE  RECTUM  AND  ANUS 


tion  of  the  mucous  membrane,  the  surface  of  a  villous  tumor 
will  be  found  to  consist  of  embryonal  cells,  or  granulation  tis- 
sue. If  a  malignant  character  is  present,  its  evidences  will  be 
found  at  the  base  of  the  tumor,  where  there  is  still  mucous 
membrane,  and  in  the  behavior  of  its  epithelium."  Allingham 
formerly  believed  that  villous  tumors  did  not  become  malig- 
nant, but  more  recently  he  reports  having  seen  eighteen  cases 
in  three  of  which  the  growths  were  replaced  by  epithehoma. 
The  author  has  frequently  seen  polypoid-like  vegetations  which 


Fig.  166. — Embryonic  Tissue  Removed  from  Dermoid  Cyst  of  the 
Sacrum  (Leitz,  3;  Ocular,  IV). 


originated  from  various  causes,   but  he  has  never  seen   one 
which  he  would  consider  a  typic  villous  tumor. 

Angioma. — A  few  cases  of  angioma  (nevus)  of  the  rectum 
have  been  reported,  but  the  author  has  never  had  an  oppor- 
tunity of  observing  this  condition.  In  the  case  reported  by 
Barker  post-mortem  examination  showed  that  the  lower  four 
and  one-half  inches  (11.4  centimeters)  of  the  rectum  were  much 
thickened  by  a  nevus,  cavernous  in  character,  which  gave  to 
the  mucous  membrane  a  purple  hue.    The  folds  of  the  mucosa 


NON-MALIGNANT  TUMORS 


491 


were  thickened,  and  two  large,  irregular  ulcers  were  promi- 
nent, which  evidently  were  responsible  for  the  frequent  hem- 
orrhages which  preceded  death.  Angiomata  may  involve  but 
a  small  area  or  may  encircle  the  bowel.  They  are  best  treated 
by  cauterization,  and  the  Paquelin  cautery  is  especially  service- 
able in  these  cases. 

Teratoma  (Dermoid  Cyst). — Dermoid  cysts  containing  hair 
and  sometimes  teeth  are  quite  frequent  over  the  sacro-coc- 
cygeal    region,    and    often    terminate    in    fistula.      In    excep- 


Fig 


167.— Epithelial  Tissue  Removed  from  a  Dermoid  Cyst  of  the 
Sacrum  (Leitz,  6;  Ocular,  IV). 


tional  cases  they  occur  in  the  rectal  wall,  and  the  hairs  are 
seen  projecting  into  the  bowel  or  out  of  the  anus.  They  vary 
from  the  size  of  a  pea  to  that  of  an  orange.  The  contents  of 
ovarian  dermoids  have  been  known  to  find  an  outlet  through 
the  rectum.  Many  cases  of  teratoma  of  the  ano-rectal  region 
have  been  recorded,  the  most  interesting  being  those  reported 
by  Danzel,  Port,  and  Molliere.  The  author  has  treated  several 
cases  of  dermoid  cysts  over  the  sacro-coccygeal  region  which 
had  caused  fistulas,  and  he  has  seen  one  such  tumor  within  the 
rectum.     The  embryonal  tissue  which  is  found  in  these  cysts 


492  DISEASES  OF  THE  RECTUM  AND  ANUS 

is  well  shown  in  the  accompanying  cuts  (Figs.  166  and  167), 
which  were  made  from  sections  taken  from  a  specimen  removed 
by  my  colleague,  Dr.  Robert  T.  Morris. 

Cystoma.  —  In  very  rare  cases  retention  cysts  containing 
the  secretions  or  excretions  of  the  rectum  or  skin  occur  in  the 
ano-rectal  region.  The  author  has  treated  but  one  case  in 
which  the  tumor  was  located  in  the  rectum.  It  was  about  the 
size  of  a  cherry,  somewhat  pedunculated,  and  filled  with  mu- 
cus. In  two  other  cases  he  removed  large  cysts  from  the  peri- 
neum, in  both  of  which  the  tumors  were  attached  by  broad 
pedicles  and  filled  with  a  thick,  whitish  fluid  and  cheesy  mate- 
rial which  resembled  sebaceous  matter.  In  both  of  these  cases 
the  attachment  of  the  tumor,  beginning  at  the  anus,  occupied 
almost  the  entire  perineum,  and  when  the  patient  was  standing 
the  cyst  appeared  very  much  like  a  scrotum.  The  larger  tumor 
was  eight  inches  (20.3  centimeters)  in  circumference,  and  the 
patient,  a  gentleman  of  fifty  years,  was  referred  to  the  author 
by  Dr.  John  Punton,  of  Kansas  City.  The  smaller  tumor  was 
about  the  size  of  an  tgg,  and  this  patient  was  a  lady,  thirty-five 
years  of  age,  who  was  referred  to  the  writer  by  his  colleague, 
Dr.  R.  W.  Wilcox.  The  treatment  in  both  cases  was  the  same : 
the  cysts  were  carefully  dissected  out,  the  wound  closed,  and 
primary  union  secured.  Prideaux  has  recorded  a  case  in  which 
he  removed  from  the  upper  part  of  the  rectum  a  large  cyst  con- 
taining about  half  a  pint  (245  cubic  centimeters)  of  thick,  albu- 
minous fluid.  Another  unusual  and  interesting  case  has  been 
reported  by  Adams  and  Parsons  Smith.  In  this  case  a  pedun- 
culated, pyriform,  semitransparent  cyst  the  size  of  a  fetal  head 
was  found  protruding  from  the  rectum  at  the  end  of  a  normal 
parturition;  the  cyst  was  tapped  and  eight  ounces  (245  cubic 
centimeters)  of  straw-colored  fluid  removed. 

Myoma. — In  a  very  few  cases  tumors  composed  of  muscular 
tissue  have  been  removed  from  the  rectum.  More  frequently, 
however,  tumors  made  up  of  both  fibrous  and  muscular  tissue 
(myoHhromata)  have  been  described.  McCosh  removed  a  tu- 
mor of  this  latter  type  which  extended  from  the  anus  to  the 
hollow  of  the  sacrum.  Microscopic  examination  showed  it  to 
be  a  myofibroma  springing  from  the  muscular  coat. 

Enchondroma.  —  One  of  the  most  rare  and  curious  rectal 
neoplasms  is  enchondroma,  which  is  made  up  of  cartilaginous 
tissue,  smooth,  hard,  firm,  and  glistening.     Among  the  very 


NON-MALIGXANT  TUMORS 


493 


few  cases  which  have  been  placed  on  record  the  most  typic 
are  those  described  by  Van  Buren  and  Dolbeau.  Bodenhamer 
suggests  that  the  cyHndric  neoplasm  of  the  rectum  which  has 
the  appearance  of  a  large  dew-worm  or  earth-worm  should  be 
classified  as  enchondroma,  "as  it  has  nearly  all  the  character- 
istics attributable  to  cartilage ;  it  has  the  firm  and  elastic  feel 
peculiar  to  cartilage;    it  is  poorly  supplied  with  blood-vessels; 


Pig.  168.— Elephantiasis  of  the  Ano-vulTar  Region 

Large  Tumor:  Largest  Diameter,  32  Inches  (82  Centimeters).  Base  Diameter, 
25  Inches  (63.5  Centimeters).  Smallest  Diameter,  12  Inches  (30.5  Centi- 
meters). 

Small  Tumor:  Largest  Diameter,  19  Inches  (48.2  Centimeters).  Base  Diam- 
eter, 13  Inches  (33  Centimeters).  Smallest  Diameter,  7  Inches  (17.8  Centi- 
meters). 

Total  Weight,  10  V2  Pounds  (4763  Grams),  Dry. 

These  measurements  were  made  and  the  tumors  weighed  twenty-two  months 
after  the  operation,  during  which  time  the  specimens  were  preserved  in 
alcohol,   causing  them  to  shrink  considerably. 


494 


DISEASES  OF  THE  RECTUM  AND  ANUS 


when  incised  a  little  sanguineo-serous  fluid  oozes  from  the  cut 
surface,  and  as  the  knife  passes  through  it  one  is  reminded  of 
cutting  gristle." 

Myxoma. — The  rarest  of  all  forms  of  rectal  neoplasms  con- 
sists of  mucous  tissue.  The  only  case  reported  where  the  diag- 
nosis was  verified  by  the  microscope  was  that  of  Jones,  in 
which  a  large  ovoid  tumor  projected  into  the  upper  part  of 
the  rectum.  When  removed  this  tumor  was  found  to  consist 
of  three  separate  growths,  the  largest  being  about  the  size  of  a 
pullet's  egg. 

Spina  Bifida. — Cysts  filled  with  spinal  fluid  are  not  uncom- 
mon over  the  sacrum.  In  rare  instances  the  opening  in  the 
bone  may  be  anteriorly,  and  the  spinal  fluid  finds  its  way  for- 
ward and  forms  a  cyst  which  projects  into  the  rectum,  causing 


Fig.  169.— Adenoid  (Soft)  Polyp. 


partial  or  complete  occlusion.  The  diagnosis  and  treatment  of 
this  form  of  tumor  are  given  in  the  chapter  on  diseases,  injuries, 
and  tumors  of  the  coccyx. 

Osteoma. — Osteoma  is  a  benign  tumor  of  bony  formation, 
which  is  said  to  have  its  origin  in  the  sacral  region  in  very  rare 
instances  and  to  assume  proportions  sufficient  to  produce 
partial  or  complete  obstruction  of  the  rectum.  The  author  has 
never  seen  such  a  case  nor  has  he  been  able  to  find  any  authen- 
ticated case  recorded. 

Ano-vulvar  Elephantiasis. — This  disease  is  characterized  by 
large,  firm,  light-colored,  usually  ovoid,  tumor-like  swellings  in 
the  ano-vulvar  region  (Fig.  168).  They  may  be  smooth  and 
covered  by  practically  normal  skin  (elephantiasis  glabra)  or  they 
may  be  irregularly  nodulated  (elephantiasis  condylomata ) .  Ele- 
phantiasis of  this  region  is  usually  the  result  of  prolonged  irrita- 


NON-MALIGNANT  TUMORS 


495 


tion  and  inflammation  of  the  parts.  It  may,  therefore,  in  rare 
instances  be  a  complication  of  syphihs,  tuberculosis,  fistula 
(Case  VI),  or  other  disease  of  the  female  genitals,  rectum,  or 
anus,  accompanied  by  an  ulceration  which  produces  an  acrid 
discharge,  keeping  the  parts  moist,  excoriated,  and  intensely 
irritated.  Elephantiasic  growths  may  be  single  or  multiple, 
isolated  or  conglomerate,  and  produce  enormous  deforming 
tumors,  which  may  become  pedunculated  owing  to  their  great 
weight.  A  striking  example  of  a  very  large  elephantiasic 
tumor  from  the  ano-vulvar  region  is  shown  in  Fig.  168,  which 
is  reproduced  from  a  photograph  of  a  tumor  removed  by  Dr. 
W.  Dufif  Bullard. 

These  tumors  appear  to  be  the  result  of  an  enormous  in- 


Fig.  170.— Fibrous  (Hard)  Polyp. 

crease  of  connective  tissue ;  in  other  words,  the  skin  and  some- 
times the  subcutaneous  structures  undergo  a  fibrosis. 


SYMPTOMS 

Clinically  polyps  may  be  divided  into  the  soft  and  hard 
(Figs.  169  and  170).  Unless  ulcerated  or  strangulated,  these 
growths  cause  little  pain,  but  induce  sensations  of  uneasiness 
and  fullness,  and  a  feeling  of  the  presence  in  the  rectum  of 
some  foreign  body  which  should  be  expelled.  The  irritation  pro- 
duced by  a  polyp  moving  about  in  the  rectum  frequently 
causes  a  proctitis,  and,  in  exceptional  cases,  ulceration;  in 
either  case,  frequent  stools  and  an  abundant  discharge  of  mu- 
cus, sometimes  mixed  with  pus  and  blood,  are  induced.  When 
the  tumor  is  large,  it  may  partially  or  completely  obstruct  the 
bowel. 


496  DISEASES  OF  THE  EECTUM  AND  ANUS 

A  polyp  may  or  may  not  protrude,  depending  on  the 
length  of  its  pedicle  and  the  amount  of  straining  it  induces. 
When  the  pedicle  is  long,  the  tumor  is  pushed  out  through  the 
anus  by  the  feces.  When  a  polyp  is  small,  it  may  return 
spontaneously;  but  when  large  it  is  necessary  for  the  patient 
to  replace  it  above  the  sphincters  after  each  stool.  If  from  any 
cause  the  growth  is  left  protruding,  it  becomes  strangulated  by 
the  sphincter-muscle  and  eventually  sloughs  off.  There  is  little 
bleeding,  unless  the  tumor  is  of  the  angiomatous  or  villous 
type  or  becomes  ulcerated  from  frequent  handling.  When 
polyps  are  multiple  and  there  is  a  profuse  irritating  discharge 
which  oozes  out  of  the  anus  and  keeps  the  parts  moist,  they 
become  excoriated,  and  a  most  intense  pruritus  is  likely  to 
follow. 

DIAGNOSIS 

When  the  polyp  protrudes,  the  diagnosis  can  sometimes 
be  made  at  a  glance.  If  the  tumor  is  situated  low  down  in  the 
rectum  within  reach  of  the  finger,  the  diagnosis  is  not  difficult, 
because  the  finger  can  be  passed  around  tJie  pedicle  of  the  bell- 
clapper-shaped  tumor.  When  located  in  the  upper  rectum  or 
sigmoid,  its  character,  size,  and  location  can  be  determined 
with  certainty  by  procto-colonoscopic  examination. 

Because  of  their  protrusion,  polyps  are  more  frequently 
confused  with  hemorrhoids  and  prolapse  than  any  other  rectal 
affection.  The  points  of  differentiation  are  given  in  the  table 
(page  427)  in  the  chapter  on  symptoms  and  diagnosis  of  inter- 
nal hemorrhoids.  Polypoid  benign  growths  in  the  rectum  have 
also  been  mistaken  for  adenocarcinomata,  but  are  easily  distin- 
guished from  the  latter  because  (a)  they  occur  in  young 
subjects,  (b)  are  pedunculated  and  more  movable,  (c)  there  is 
no  cachexia,  (d)  frequently  protrude,  (e)  are  odorless,  (f)  do 
not  involve  the  adjacent  structures,  and  (g)  are  less  rapid  in 
their  growth.  However,  it  must  not  be  forgotten  that  simple 
adenomata,  polyposis,  and  villous  tumors  may  undergo  can- 
cerous degeneration,  and  when  there  is  any  doubt  in  these  cases 
tlie  diagnosis  sJioidd  be  verified  by  tlie  microscope.  In  discussing 
the  differential  diagnosis  between  benign  and  malignant 
growths  of  the  rectum  Van  Buren  suggested  that,  "in  pro- 
portion as  a  tumor  becomes  pedunculated,  the  danger  of  its 
being  malignant  lessens,"  and  the  writer's  experience  has  been 
in  accord  with  this. 


NON-MALIGNANT  TUMORS 


497 


PROGNOSIS 

Polyps  tend  to  increase  in  size  and  the  pedicle  gradually 
becomes  longer,  unless  the  growth  is  removed  or  sloughs  off. 
They  frequently  attain  such  proportions  that  prolapse  or  intus- 
susception of  the  bowel  may  result  from  the  constant  downward 
traction  of  the  tumor.  The  prognosis  is  good  in  true  non- 
malignant  tumors  of  the  rectum,  because  they  usually  do  not 
recur  after  removal.  But  in  cases  of  polyadenoma  and  other 
benign  growths  which,  as  stated  above,  may  undergo  cancerous 
degeneration,  the  prognosis  is  more  unfavorable,  and  it  is 
certainly  best  to  keep  these  patients  under  close  observation. 


Fig.  171.— Removing  a  Polyp  with  the  Gant  Clamp. 


TREATMENT 

A  spontaneous  cure  of  polyps  sometimes  results  from  de- 
tachment by  the  fecal  mass  or  strangulation  by  the  sphincter- 
muscle  causing  them  to  slough  off. 

Little  can  be  accomplished  by  non-surgical  measures  in  the 
treatment  of  benign  tumors  of  the  rectum  other  than  adding 
to  the  patient's  comfort  by  returning  the  protruded  tumor  into 
the  rectum,  keeping  the  parts  clean,  regulating  the  stools,  and 
prescribing  some  soothing  or  stimulating  ointment  when  the 
tumor  is  ulcerated. 


498  DISEASES  OF  THE  RECTUM  AND  ANUS 

The  safest  and  by  far  the  most  satisfactory  method  of 
treatment  in  these  cases  is  removal  of  the  tumors  at  the  earliest 
opportunity.  Pedunculated  growths  should  be  grasped  with 
forceps,  pulled  well  down,  clamped  at  the  base  (Fig.  171), 
cut  off,  and  cauterized  with  the  Paquelin  cautery.  The  next 
best  method  is  to  ligate  the  pedicle  at  its  attachment  and  cut 
away  the  part  of  the  tumor  external  to  the  ligature.  When 
the  tumors  are  located  in  the  upper  rectum  or  sigmoid,  these 
operations  are  not  practicable,  and  it  is  necessary  to  remove 
them  by  the  snare  or  torsion.  The  author  has  devised  a  special 
pair  of  forceps  (Fig.  172)  by  the  aid  of  which  polyps  can 
be  quickly  and  safely  removed  by  torsion  from  any  part  of 
the  rectum  and  lower  sigmoid  through  a  long  colonoscope ;  if 
there  is  considerable  bleeding  and  it  is  necessary  to  pack  the 
rectum,  the  forceps  can  also  be  used  for  this  purpose. 

In  some  cases  where  the  tumors  are  fairly  low  down  and 


Fig.  172.— Gant's  Recto-colonic  Forceps  for  the  Removal  of  Polyps, 
Foreign  Bodies,  and  Dressings. 

have  a  thick  attachment,  they  may  be  transfixed  with  a  needle 
carrying  a  double  ligature,  which  is  tied  on  either  side.  Angi- 
omatous tumors  having  a  broad  base  can  be  satisfactorily  de- 
stroyed by  ligating  them  in  sections,  or  they  may  be  excised 
and  their  base  cauterized.  In  cases  of  polyadenoma  (polypo- 
sis) where  the  tumors  are  small  and  numerous  they  should  be 
carefully  burned  away  with  the  Paquelin  cautery-point.  On 
the  other  hand,  when  they  are  of  such  size  and  numbers  as  to 
produce  obstruction,  it  may  be  necessary  to  perform  colostomy, 
making  the  opening  above  the  site  of  the  growths.  The  writer 
thought  it  advisable  to  do  this  in  one  case  and  was  much 
pleased  with  the  results,  because  this  operation  enabled  him  to 
keep  the  bowel  below  the  opening  perfectly  clean,  and  to  re- 
move the  tumors  both  from  above  and  below  at  opportune 
times.  Six  months  after  the  artificial  anus  was  established  the 
growths  were  completely  destroyed  and  the.  opening  closed. 


NON-MALIGNANT  TUMORS  499 

Tumors  of  the  rectum  or  upon  the  surface  of  the  body  in 
the  ano-gluteal  region  should  be  excised  in  suitable  cases.  The 
wound  may  be  immediately  closed  or  left  to  heal  by  granula- 
tion. 

The  Treatment  of  Elephantiasis  about  the  ano-vulvar  region 
consists  in  removing  the  source  of  irritation,  and  total  extir- 
pation of  the  tumors  when  this  is  feasible.  In  one  case  success- 
fully operated  upon  by  the  author  the  combined  weight  was  three 
pounds  (1450  grams), 

ILLUSTRATIVE  CASES 

Case  XXXV.  Polyp  Weighing  Four  Ounces  (120  Grams).  Removed 
by  the  Ligature  Operation. — In  IS95  I  was  called  in  consultation  to  see  a 
gentleman,  40  years  of  age,  thought  to  be  dying  from  cancer  of  the  rectum. 
The  patient  was  anemic,  emaciated,  and  extremely  nervous.  He  informed  me 
that  during  the  eighteen  months  previous  he  suffered  from  diarrhea,  and  went 
to  the  closet  from  fifteen  to  twenty  times  daily.  No  solid  matter  was  evacu- 
ated during  stool,  the  dejecta  being  composed  of  liquid  feces,  mucus,  and 
blood.  Defecation  was  exhausting  and  extremely  painful  because  of  tenesmus, 
straining,  and  a  bearing-down  sensation  as  of  the  presence  of  a  foreign  body 
in  the  rectum.  The  growth  frequently  came  down  to  the  anus,  but  never 
protruded.  The  patient  said  that  he  had  been  examined  by  several  reputable 
physicians,  and  all  had  pronounced  it  cancer  and  told  him  that  he  had  but 
a  short  time  to  live. 

Examination.- — The  patient  was  placed  on  his  left  side  and  requested 
to  bear  down  with  all  his  might.  As  he  did  so  the  sphincter  gradually  re- 
laxed and  the  tumor  came  into  view,  completely  blocking  up  the  anal  canal; 
but  it  could  not  be  entirely  seen.  It  was  movable,  irregularly  globular  in 
shape,  ulcerated,  purple  in  color,  and  smeared  with  pus,  blood,  and  mucus. 
It  was  not  difficult  to  understand  how  it  might  be  mistaken  for  a  malignant 
growth.  A  digital  examination  was  attempted,  but  it  was  found  impossible 
to  introduce  the  finger  past  the  tumor.  The  patient  was  then  anesthetized 
and  the  sphincter  divulsed,  when  with  difficulty  the  finger  was  introduced 
above  and  around  the  growth.  The  tumor  was  found  attached  three  inches 
(7.62  centimeters)  above  the  anus  by  a  pedicle  half  an  inch  (1.27  centimeters) 
thick  and  somewhat  more  than  one  inch  (2.54  centimeters)  in  length.  His 
family  was  informed  that  the  growth  was  not  cancerous  and  that  it  could  be 
safely  removed.  It  was  suggested  that  this  be  done  at  once  while  the  patient 
was  under  the  anesthetic.  Consent  was  obtained,  and  I  operated  as  follows: 
The  tumor  was  grasped  between  the  index  and  middle  fingers  inserted  into 
the  rectum,  and  drawn  down  and  out  through  the  anus,  where  it  was  held 
by  an  assistant.  A  strong  silk  ligature  was  then  tied  around  the  base  of  the 
pedicle  and  the  portion  of  the  tumor  external  to  it  cut  away.  Dressings  were 
applied  and  the  patient  placed  in  bed.  He  suffered  no  inconvenience  from  the 
operation  and  was  discharged  within  a  week.  The  tumor  removed  weighed 
four  ounces  (120  grams).  Microscopic  examination  showed  it  to  be  a  simple 
adenoma. 


500  DISEASES  OF  THE  EECTUM  AND  ANUS 

Case  XXXVI.  Polyps  in  a  Child  Three  Years  of  Age.  Removed  toy 
Torsion. — I  was  called  to  Brooklyn  to  see  a  little  girl,  3  years  of  age,  whose 
mother  said  the  trouble  was  "piles."  The  child  suffered  from  constipation 
and  diarrhea  alternately.  The  feces  were  always  streaked  with  blood,  and 
contained  considerable  glairy  mucus  resembling  the  white  of  an  egg.  Not 
infrequently  she  had  a  desire  to  stool,  but  nothing  was  evacuated.  Beyond 
slight  discomfort,  she  suffered  little  pain  except  during  stool,  when  suffering 
was  acute,  but  subsided  shortly  afterward.  The  mother  said  that  each  time 
the  child  had  an  action  two  small,  red  bunches  came  out  at  the  anus,  and 
that  these  sometimes  bled  freely. 

Examination. — ^Digital  examination  with  the  little  finger  revealed  the 
presence  of  two  small  polyps,  each  about  the  size  of  a  cherry;  one  was 
situated  posteriorly  in  the  median  line,  one  inch  (2.54  centimeters)  above  the 
anus,  and  the  other  was  located  on  the  left  lateral  wall,  half  an  inch  (1.27 
centimeters)  higher  up. 

Treatment. — The  child  was  placed  in  the  hospital  and  on  the  following 
day  was  operated  upon  as  follows:  The  sphincter  was  divulsed,  and  the 
tumors  exposed  by  the  author's  office-speculum.  The  polyps  were  somewhat 
irregular  in  shape,  and  not  unlike  a  strawberry.  Each  in  turn  was  seized 
with  catch-tooth  forceps,  pulled  well  down,  and  twisted  off.  The  little  patient 
was  then  placed  in  bed.  She  was  confined  to  the  house  but  one  day,  and  made 
an  uninterrupted  recovery. 

Case  XXXVII.  Large  Fibrous  Polyp  of  Several  Years'  Standing. — I 
was  requested  to  examine  a  banker  from  a  neighboring  State.  His  family 
physician  gave  the  following  history  of  the  case:  The  patient  had  a  "pile"' 
which  had  been  coming  down-  for  several  years  after  each  stool;  it  would 
bleed  at  times,  but  until  recently  he  could  easily  replace  it.  Now  the  tumor 
was  so  large  that  it  was  exceedingly  difficult  to  return.  Of  late  there  had 
been  frequent  discharges  of  mucus,  which  irritated  the  skin,  causing  consid- 
erable pruritus.  He  was  unable  to  sleep  or  keep  his  mind  on  business,  and 
was  very  anxious  to  be  cured.  He  was  placed  on  the  table  and  a  digital 
examination  made.  The  finger  easily  passed  the  tumor,  which  was  found 
to  be  attached  above  by  a  pedicle  the  size  of  the  little  finger.  Both  doctor 
and  patient  were  much  sui-prised  when  informed  that  there  were  no  piles, 
but  a  polyp  which  could  be  speedily  removed.  The  patient  was  anesthetized, 
placed  in  the  lithotomy  position,  the  sphincters  divulsed,  the  polyp  pulled 
down  by  catch-forceps,  and  the  pedicle  ligated  with  strong  silk  at  its  junction 
with  the  mucous  membrane.  With  a  pair  of  scissors  the  pedicle  was  severed 
about  one-fourth  of  an  inch  (6.3  millimeters)  exteraal  to  the  ligature;  the 
rectum  was  irrigated,  and  the  patient  put  to  bed.  On  the  fifth  day  the 
patient  returned  to   his  home   and  had  no  further  trouble  with  his  rectum. 

Case  XXXVIII.  Adenoid  Polyps.  Removed  toy  Clamp  and  Cautery. — A 
lady,  aged  40,  came  to  me  to  be  treated  for  rectal  disease.  Examination 
revealed  the  presence  of  two  small  adenoid  polyps  about  an  inch  (2.54  centi- 
meters) in  length,  attached  to  the  right  wall  of  the  rectum  at  the  upper 
margin  of  the  internal  sphincter.  They  were  promptly  clamped,  excised,  and 
cauterized.     The  patient  recovered  perfectly  within  ten  days. 


NON-MALIGNANT  TUMORS  501 

LITERATURE    ON    NON-MALIGNANT    GROWTHS    (POLYPS) 


Adams  and  Smith:    "Cystoma,"  Lancet,  London,  vol.  ii,  p.  881,  1883. 
Allingham:    "Polypus  Recti,"  "Diseases  of  the  Rectum  and  Anus,"  pp.  189-197, 

1888. 
Ball:    "Benign  Neoplasms,"  "The  Rectum  and  Anus,"  pp.  280-302,  1887. 
Bardenheuer:    "Multiple  Glandular  Growths,"  etc.,  Arcliiv  f.  klin.  Chirurgie, 

xli,  1893. 
Barker:    "Angioma,"  Medico-CMrurgical  Trans.,  vol.  Ixvi,  1883. 
Bodenhamer:     "The   Non-malignant   Neoplasm,"   etc.,   N.    Y.   Med.   Jour.,   vol. 

Ixviii,  p.  230-267,  1898. 
Bowlby:    "Fibroma,"  Trans.  London  Path.  Society,  1883. 
Broca:     "Traite  des  Tumeurs,"  vol.  ii,  p.  556.     Paris,  1864. 
Cripps:    "Polypus,"  "Diseases  of  the  Rectum  and  Anus,"  p.  268,  1898. 
Danzel:    "Rectal  Dermoid"  (reported  by  Langenbeck),  Arcliiv  f.  klin.  L'hirurgie, 

p.  442,  1874. 
Dennis:     "Tumors  of  Large  Intestine,"  "System  of  Surgery,"   vol.  iv,  p.   462, 

1896. 
Dolbeau:    "Enchondroma,"  Bulletin  de  la  Societe  Anatomique  de  Pai'is,  2  Serie, 

t.  V,  p.  6,  1860. 
Esmarch:   "Diseases  of  the  Rectum  and  Anus,"  Deutsche  Chirurgie,  Pt.  XLVIIL 
Huber:    "Etiology  of  Rectal  Polypi  in  Children,"  Archives  of  Pediat.,  p.  685,, 

Sept.,  1901. 
Jones:    "Myoma,"  Lancet,  London,  vol.  ii,  p.  956,  1887. 
Kelsey:    "Non-malignant  Growths,"  "Diseases  of  the  Rectum  and  Anus,"  pp. 

263-290,  1890. 
Laveneren:    "Diagnosis  of  Polyps,"  etc.,  Archives  de  Physiol.,  iii,  1876. 
Leichtenstern:    "Intestinal  Polypi,"  Ziemssen's  "Cyclopedia,"  vol.  vii,  p.  634, 

1876. 
Luschka:    Virchow's  Archiv,  Bd.  xx,  p.  133,  1861. 

Mathews:    "Villous  Tumors,"  "Diseases  of  the  Rectum  and  Anus,"  p.  515,  1896o 
Maylard:    "Innocent  Tumors,"  "Surg.  Alimentary,"  p.  602,  1896. 
McCosh:     "Myoma,"  "Amer.  Surg.,"  vol.  xviii,  p.  41,  1893. 
Port:    "Teratoma,"  Trans.  Path.  Society,  vol.  xxxi,  p.  307,  1880. 
Pozzi:    "Rectal  Adenoma,"  Gazette  Medicale  de  Paris,  Oct.  25,  1884. 
Prideaux:    "Cystoma,"  Lancet,  London,  vol.  ii,  p.  633,  1883. 
Quenu   and   Hartmann:     "Tumeurs   de   Rectum,"    "Chirurgie    du   Rectum,"    p. 

576,  1899. 
Sangelle:    "Pathologie  des  Tumeurs,"  t.  1,  pp.  2,  379,  1876. 
Senn:    "Papilloma,"  "Path,  and  Surg.  Treat.  Tumors,"  pp.  137-151,  1895. 
Van  Buren:     "Polypus  and  Benign  Tumors,"   "Diseases  of  the  Rectum,"  pp. 

95-127,  1882. 
Virchow:    "Pathologie  des  Tumeurs,"  vol.  1,  p.  379.     Paris,  1867. 
Wells:    "Specimen  of  Lobulated  Fatty  Tumor,"  Trans.  London  Path.  Society, 

vol.  xvi,  p.  277,  1865. 
Ziegler:    "Tumors  of  the  Intestine,"  "Spec.  Path.  Anat."    (American  ed.),  pp. 

676-80,  1898. 
Zupper:    Wien.  klin.  Woch.,  1901. 


CHAPTER  XXXII 

CLASSIFICATION,  ETIOLOGY,  PATHOLOGY,  SYMPTOMS,  DI- 
AGNOSIS, AND  PROGNOSIS  OF  MALIGNANT  TUMORS 
(CARCINOMA  [TRUE  CANCER]  AND  SARCOMA) 

In  the  preceding  chapter  the  author  discussed  non-mahg- 
nant  tumors  of  epithelial  and  connective-tissue  types,  and  those 
which,  although  primarily  innocent,  may  become  malignant. 
Hence,  in  this  chapter,  epithehal  and  connective-tissue  neo- 
plasms of  malignant  or  cancerous  nature  will  be  considered. 

Cancer  is  encountered  far  more  frequently  in  civilized  than 
in  uncivilized  countries,  and  statistics  show  that  it  is  increasing 
yearly.  Senn,  however,  says :  "The  increase  of  carcinoma,  as 
claimed  by  some  writers,  is  more  apparent  than  real."  The 
disease  is  most  prevalent  in  the  low-lying  districts  of  England 
and  in  the  United  States,  while  in  Turkey,  Egypt,  the  West 
Indies,  and  all  tropic  countries  it  is  of  rare  occurrence.  In 
the  United  States  cancer  is  more  common  in  New  York,  Penn- 
sylvania, and  parts  of  California  than  in  the  Mississippi  Valley 
and  the  Southern  States.  It  is  practically  unknown  among  the 
Indians  and  other  savage  races,  is  extremely  rare  among  the 
negroes,  and  is  said  to  attack  the  idiotic  and  insane  much  less 
frequently  than  persons  of  greater  intelligence  and  those  bur- 
dened with  the  cares  of  active  life. 

There  is  a  wide  range  of  difference  between  the  statistics 
collected  by  authors  to  show  the  percentage  of  deaths  from 
cancer  as  compared  with  those  from  other  diseases.  Williams's 
statistics  show  that,  out  of  a  mortality  of  10,512,146,  there  were 
177,300  deaths  from  cancer,  or  an  average  cancer-mortality  of 
1  in  59  deaths.  The  statistics  of  Cripps  show  that,  out  of  the 
2,679,622  persons  over  twenty  years  of  age  who  died  in  Eng- 
land and  Wales  during  the  ten  years  just  previous  to  1870, 
cancer  was  the  cause  of  death  in  81,699  instances;  or,  in  other 
words,  1  out  of  every  29  deaths  was  due  to  this  disease.  Leich- 
tenstern's  analysis  of  the  34,523  deaths  occurring  in  the  Kaiser 
und  Kaiserin  Allgemeines  Krankenhaus  in  Vienna,  between  the 
years  1858  and  1870,  shows  that  1874,  or  5.4  per  cent.,  were 
the  result  of  cancer. 
(503) 


EXPLANATION  OF  PLATE  XXIX 


Above  is  a  cell-nest,  or  epithelial  pearl,  composed  of 
homy  material,  the  product  of  the  surrounding  layers  of 
epithelial  cells,  representing  the  rete  Malpighii  of  the 
epidermis.  On  the  right  of  the  pearl  can  be  seen  some 
traces  of  the  stratum  granulosum  between  the  horny 
material  and  the  epithelial  cells. 

Outside  of  the  epithelial  layers  is  a  stroma  of  fibers 
and  spindle-shaped  cells,  indicating  the  white,  fibrous 
tissue  of  which  it  is  composed. 

To  the  left  are  two  small  epithelial  pearls  in  an 
earlier  stage,  enveloped  by  an  area  of  round-cell  infiltra- 
tion called  into  existence  by  the  irritation  caused  by  the 
advanciug  growth. 


PLMTE  XXIX 


Epitheliania  of  the  Mnus,      MagniScatian,  250. 


MALIGNANT  TUMORS  503 

Cancer  is  pre-eminently  a  disease  of  adult  life,  though  sev- 
eral cases  have  been  reported  in  persons  under  twenty  years 
of  age. 

Authors  generally  agree  that  women  suffer  from  malignant 
disease  more  frequently  than  men,  as  the  following  statistics 
will  show:  Out  of  the  177,300  deaths  from  cancer  in  all  parts 
of  the  body  mentioned  above  by  WilHams,  53,867  were  males, 
and  123,433  females. 

No  organ  of  the  body  is  exempt  from  cancer.  In  the  rec- 
tum, which  is  one  of  its  favorite  points  of  attack,  it  is  undoubt- 
edly the  most  distressing  and  fatal  affection  with  which  the 
proctologist  has  to  contend.  Malignant  growths  attack  the 
rectum  primarily,  though  in  a  few  instances  the  rectum  is  said 
to  have  been  secondarily  involved.  To  show  the  relative  fre- 
quency with  which  the  various  organs  develop  cancer,  WilHams 
has  compiled  the  following  table,  based  upon  an  analysis  of 
7297  cases,  which  gives  a  fair  idea  of  the  frequency  of  malig- 
nant disease  of  the  rectum  as  compared  with  the  other  or- 
gans : — 

Table  XV.    Statistics  of  Canceb 
Females  (4628  Cases)  Males  (2699  Cases) 

Breast 40.3    percent.      Tongue  and  mouth...   26.3     percent. 


Uterus 34.0 

Rectum    4.3 

External  genitalia ....  3.4 

Skin   4.1 

Stomach    2.8 

Liver    2.5 

Tongue  and  mouth...  2.18 

Intestines   1.06 

Esophagus    0.70 

Lips    0.06 

All  other  localities . .  .  4.60 


Skin  14.3 

Lip    12.2 

Rectum     7.5 

Stomach    8.3 

External  genitalia  ....  6.8 

Esophagus    5.3 

Liver    4.4 

Intestines    1.9 

Breast    0.6 

Prostate    0.3 

All  other  localities...  12.1 


100.00  per  cent.  100.00  per  cent. 

From  this  table  it  would  appear  that,  out  of  7297  cases 
of  cancer  of  all  organs  of  the  body,  5.9  per  cent,  were  located 
in  the  rectum. 

The  author  has  compiled  the  following  table  from  another 
series  of  cases  collected  by  Williams,  to  show  the  relative  fre- 
quency of  malignant  disease  (epithelioma  and  sarcoma)  of  the 
intestine  and  its  various  parts : — 


504  DISEASES  OF  THE  RECTUM  AND  ANUS 

Table  XVI.     Statistics  of  Ano-eectai.  Cancer 

Total  number  of  cases   (all  organs  of  the  body) 9228 

Number  occurring  in  the  intestines 534 

Number  occurring  in  the  rectum 408 

Number  occurring  at  the  anus 27 

Number  occurring  in   other  parts   of  the  intestines 99 

From  this  it  would  appear  that  81.4  per  cent,  of  these  ma- 
lignant growths  occurring  in  the  intestines  are  located  about 
the  rectum  and  anus. 

Leichtenstern  gives  the  following  percentages  for  cancer 
of  the  intestine  : — 

Table  XVII.     Statistics  of  Intestinal  Cancer 

Cancer  of  the  rectum 80.0  per  cent,- 

Cancer  of  the  colon   11.5         " 

Cancer  of  the  cecum    (including    the    ilio-cecal    valve 

and  appendix)    4.1 

Cancer  of  the  small  intestine   4.3         " 

From  the  statistics  of  others  reviewed  and  analyzed  by  the 
author,  together  with  his  personal  experience,  he  has  found  that 
4  per  cent,  of  all  cancers  and  approximately  80  per  cent,  of  all 
intestinal  cancers  are  located  in  the  rectum.  To  give  some  idea 
of  the  proportion  of  cancer  to  other  affections  of  the  rectum, 
the  4000  cases  of  rectal  disease  observed  by  Mr.  Allingham  in 
St.  Mark's  Hospital,  London,  may  be  taken  as  a  basis.  Out  of 
this  number  105  cases  were  cancer,  and  from  this  it  would  ap- 
pear that  malignant  disease  constitutes  approximately  2.6  per 
cent,  of  all  rectal  diseases.  The  author  believes,  however,  that 
this  percentage  is  too  low. 

Malignant  neoplasms  of  the  rectum  are  very  rare  in  child- 
hood, not  common  between  the  ages  of  twenty  and  forty,  and 
most  frequent  between  forty  and  sixty,  after  which  age  the 
disease  gradually  diminishes  in  frequency,  but  few  cases  having 
been  reported  in  extreme  old  age.  Of  the  few  published  cases 
of  rectal  carcinoma  in  childhood,  the  following  are  the  most 
widely  quoted :  Child  of  G  years,  epithelioma,  reported  by  De- 
pres;  girl  of  12  years,  Zupper;  boy  of  12  years.  Mayo;  boy  of 
13,  Gowland;  boy  of  15,  Godwin;  boy  of  16,  Busk;  girl  of  13, 
Czerny;  two  girls  of  17,  Schoening;  boy  of  IT  (encephaloid), 
Allingham ;   and  a  boy  of  17,  Cripps. 

The  author  has  treated  three  lads,  aged,  respectively,  16, 
17,  and  20  years,  who  he  believes  were  suffering  from  carci- 


MALIGNANA  TUIMORS  505 

noma  of  the  rectum.  All  the  clinic  manifestations  of  the  disease 
were  present,  and  microscopic  examination  of  tissue  removed 
in  each  case  proved  conclusively  that  it  was  adenocarcinoma. 
In  two  of  these  cases  left  inguinal  colostomy  was  performed, 
and  in  the  third  the  growth  was  removed  by  the  Kraske  method. 
In  all  three  instances  death  ensued  within  one  year  after  the 
operation.  The  author  has  also  treated  six  persons  between  the 
ages  of  twenty  and  twenty-four  years,  each  of  whom  manifested 
the  usual  symptoms  of  rectal  carcinoma.  The  disease  termi- 
nated fatally  at  periods  ranging  from  four  months  to  two  years 
after  the  patients  were  first  seen.  The  diagnosis  in  these  cases, 
based  upon  digital  and  proctoscopic  examination,  was  unsatis- 
factory, as  the  writer  was  not  permitted  to  remove  any  tissue, 
and  therefore  could  not  confirm  his  opinion  by  means  of  the 
microscope.  From  this  experience  the  author  is  forced  to 
believe  that  malignant  disease  of  the  rectum  is  much  more 
common  in  early  life  than  is  generally  supposed. 

As  already  stated,  the  relative  frequency  of  rectal  cancer  in 
the  sexes  has  long  been  the  subject  of  discussion.  In  the 
writer's  practice  52  per  cent,  of  his  cases  of  rectal  cancer  have 
been  males  and  48  per  cent,  females.  Authorities  generally 
agree  that  men  are  the  more  frequent  sufferers  from  rectal 
cancer.  Billroth  placed  the  proportion  of  males  to  females  at 
10  to  8 ;  Berard,  20  to  23 ;  Rokitansky,  15  to  IT ;  and  Henck, 
1.8  to  1;  while  the  statistics  of  Stierling,  Bryant,  and  Hild- 
brand  show  2  males  to  1  female.  Kelsey  found  50  in  males  and 
57  in  females.  Of  the  435  cases  of  malignant  growths  (epithe- 
lioma and  sarcoma)  of  the  rectum  tabulated  by  Williams,  221 
were  males  and  214  were  females. 

CLASSIFICATION 

Formerly  malignant  tumors  of  the  rectum  were  classified 
as  epithelioma,  melanoma,  scirrhus,  colloid  and  medidlary  growths,, 
and  the  various  forms  of  sarcoma,  but  more  recent  investigations 
have  demonstrated  that  all  except  melanoma  and  the  last 
named  possess  the  characteristic  features  of  carcinoma,  and 
they  are  now  regarded  as  forms  of  this  disease.  Therefore- 
malignant  tumors  of  the  rectum  may  be  classified  as : — 

1.  Carcinoma — composed  of  epithelial  tissue. 

2.  Sarcoma — composed  of  connective  tissue. 
Carcinoma  of  the  rectum  is  of  common  occurrence  and  is 


506  DISEASES  OF  THE  RECTUM  AND  ANUS 

most  fatal.  Sarcoma  is  exceedingly  rare  in  this  region.  Out 
of  435  cases  of  malignant  tumors  of  the  ano-rectal  region 
tabulated  by  VVilHams,  there  were  428  cases  of  carcinoma  and 
but  7  of  sarcoma.  The  statistics  of  other  authorities  agree  in 
the  main  with  these  figures.  It  is  obvious,  therefore,  that  car- 
cinoma is  of  far  greater  importance  to  the  proctologist,  and 
will  be  the  more  fully  discussed  in  this  chapter. 

A  carcinoma  ( xapxLVog,  a  crab ;  6[ia,  tumor),  or  true 
cancer,  so  called  because  of  its  numerous  claw-like  venous 
markings,  is  an  organoid  neoplasm  of  uncertain  origin,  having 
a  tendency  to  destroy  adjacent  tissue  and  produce  metastasis. 
It  is  characterized  by  a  vascular  connective-tissue  stroma 
forming  alveoli,  containing  proliferating  epithelial  cells  of 
variable  size  and  shape,  apparently  devoid  of  intercellular  sub- 
stance. 

A  sarcoma  (aap^,  flesh ;  o^a,  tumor)  is  a  highly-vascular, 
malignant  connective-tissue  neoplasm,  characterized  by  an  ex- 
cessive development  of  embryonic  cells,  of  various  sizes  and 
shapes,  which  are  separated  from  each  other  by  more  or  less 
of  a  demonstrable  intercellular  substance,  of  a  homogeneous, 
granular,  or  fibrillary  nature  (Plates  XXXIII  and  XXXIV). 

ETIOLOGY 

Carcinoma  may  occur  in  any  part  of  the  rectum  or  at  the 
anus,  but  is,  by  far,  less  frequent  in  the  latter  locality.  Out 
of  428  cases  of  rectal  epithelioma  (true  cancer)  studied  by 
Williams,  401  were  in  the  rectum  and  but  27  at  the  anus. 

Notwithstanding  the  enormous  amount  of  time  and  labor 
expended  by  investigators  in  their  efforts  to  determine  the 
cause  of  cancer,  the  etiology  of  this  most  fatal  disease  has  not 
yet  been  satisfactorily  demonstrated.  Many  theories  as  to  its 
origin  have  been  advanced  and  ably  defended  by  different 
scientists.  The  following  are  those  which  have  attracted  the 
most  attention : — 

Cohnheim's  Theory. — Cohnheim  maintained^  that  the  cell- 
proliferation  in  carcinoma  is  not  due  to  mature  pre-existing 
tissue,  but  is  from  a  matrix  of  embryonic  epithelial  cells.  This 
theory  has  been  accepted  and  upheld  by  many,  among  others, 
Waldeyer  and  Senn.    The  views  of  Cohnheim's  followers  have 


1  Vorlesungen  iiber  allg.  Path..  2te  Auf.,  Bd-  i.  pp.  736  et    seq.,  1882. 


explanatio:n'  of  plate  xxx 


A  portion  of  adenocarcinoma,  highly  magnified, 
taken  from  the  inner  muscular  coat. 

In  the  center  is  an  alveolus  with  patent  lumen  lined 
with  columnar  epithelium.  The  central  alveolus  and  the 
three  smaller  ones  surrounding  it  are  imbedded  in  a  layer 
of  white,  fibrous  tissue,  the  wavy  bundles  of  which  can 
be  easily  traced,  while  beyond  the  fibrous  tissue,  best  seen 
on  the  right  of  the  photograph,  are  the  elongated  smooth 
muscle-fibers  of  the  muscular  coat. 


PL/ITE  XXX 


Uylindric- Celled  /Idsnacarcinnma  of  the  Rectum.     [Magnificatian,  250.] 


MALIGNANT  TUMORS  507 

been  well  expressed  by  Senn,  who  says :  "The  matrix  of  embry- 
onic cells  furnishes  the  essential  material  for  the  construction 
of  a  carcinomatous  tumor;  the  exciting  causes  simply  set  in 
motion  the  machinery  which  increases  the  building  material." 

To  substantiate  Cohnheim's  theory,  it  has  been  pointed 
out  that  primary  carcinoma  may  originate  in  bone;  but  that 
such  a  growth  is  primary  is  not  clearly  established. 

Again,  it  is  said  that  moles  composed  of  connective  tissue 
may  degenerate  into  epithelioma.  Against  the  embryonic 
theory  one  of  the  strongest  arguments  is  the  fact  that  carci- 
noma occurs  in  childhood  in  only  extremely  rare  instances. 
Park  maintains  that  there  is  nothing  contained  within  the 
theory  of  Cohnheim  which  can  ever  explain  the  peculiar  behavior 
of  the  cells  which  constitute  the  essential  feature  of  malignant 
growths,  but  that  it  may  account  for  the  presence  of  certain 
cells  in  unusual  localities. 

Parasitic  Theory.  —  This  theory  has  attracted  wide-spread 
attention.  Its  adherents  stoutly  maintain  that  cancer  is  un- 
doubtedly of  parasitic  origin.  Others  as  positively  assert  that 
such  is  not  the  case.  This  explanation  of  the  origin  of  cancer 
has  been  suggested  because  of  the  peculiar  growth  of  the 
tumor,  the  formation  of  metastases,  the  effect  of  carcinoma  on 
the  general  health  of  the  patient,  and  its  resemblance  in  other 
respects  to  infectious  diseases  of  known  parasitic  origin. 

Ziegler  says :  "Unfortunately,  most  of  those  things  which 
have  been  described  as  parasites  (viz. :  protozoa,  and  especially 
the  sporozoa  and  the  yeast-fungi)  have  not  been  parasites  at 
all,  but  degenerated  nuclei  and  karyokinetic  figures,  or  leuco- 
cytes (or  the  products  of  their  destruction),  which  have  been 
included  in  tumor-cells  or  products  of  the  cell-protoplasm,  espe- 
cially the  keratohyalin  and  colloid. 

'Tn  the  few  cases  in  which  genuine  parasites  have  been 
found  in  the  tissues,  they  may  perfectly  well  have  entered  after 
the  tumor  had  begun  to  develop.  Under  such  circumstances 
they  can  in  no  sense  be  looked  upon  as  the  cause  of  the  devel- 
opment of  the  carcinoma." 

Senn,  in  opposing  the  parasitic  origin  of  cancer,  says: 
^'The  positive  results  of  implantation  and  inoculation  experi- 
ments have  so  far  failed  in  establishing  beyond  all  doubt,  upon 
a  bacteriologic  and  histologic  basis,  the  parasitic  theory  of  car- 
cinoma." 


508  DISEASES  OF  THE  RECTUM  AND  ANUS 

In  support  of  the  parasitic  or  infectious  theory  of  cancer 
Park  holds  that  it  is  the  only  one  which  satisfies  the  needs  of 
both  the  pathologist  and  the  clinician.  He  states  that  the  para- 
site of  cancer  appears  to  belong  to  the  protozoa,  or  a  still  lower 
and  less  known  animal  form,  showing  ameboid  movements,  and 
that  these  organisms  can  be  cultivated  and  successfully  inocu- 
lated. In  regard  to  inoculation  and  implantation  he  says :  "It 
certainly  is  not  too  strong  a  statement,  then,  if  I  claim  that  in 
the  Buffalo  Laboratory  Dr.  Gaylord  and  our  staff  have  abso- 
lutely produced  adenocarcinoma  by  inoculation  in  a  number 
of  animals,  and  that  this  can  now  be  produced  in  such  a  way 
as  to  afford  unmistakable  evidence  of  the  infectivity  of  the 
disease." 

In  the  author's  opinion,  the  advocates  and  adherents  of  the 
parasitic  theory  have  not  yet  established  an  unassailable  basis 
for  their  claims. 

Traumatic  Theory.  —  The  part  played  by  trauma  in  the 
production  of  cancer  has  at  all  times  excited  much  interest. 
The  most  striking  examples  of  cancer  which  are  apparently  the 
result  of  traumatism  are  epithelioma  of  the  lips  following  pipe- 
smoking  and  carcinoma  of  the  scrotum  in  chimney-sweeps,  of 
the  limbs  in  paraf^n-  and  tar-  workers,  and  of  the  cervix  after 
laceration. 

While  numerous  cases  of  cancer  are  recorded  following  a 
single  injury, — i.e.,  of  the  breast, — in  the  majority  of  instances 
where  traumatism  is  assigned  as  the  cause  of  the  growth  there 
is  evidence  of  successive  injuries  or  long-continued  irritation. 

The  frequency  of  carcinoma  in  the  recto-anal  region  ap- 
pears to  favor  the  traumatic  theory,  for  the  reason  that  the 
rectal  mucosa  and  the  skin  about  the  anus  are  in  many  cases 
almost  daily  subjected  to  stretching  and  bruising  by  hard- 
ened feces,  and  to  injury  and  constant  irritation  caused  by  for- 
eign bodies,  lumps  of  undigested  food,  etc.,  in  the  feces  and  by 
foul  gases  and  irritating  discharges. 

Some  writers  maintain  that  the  cell-proliferation  forming 
the  neoplasm  is  due  directly  to  the  trauma,  while  others  hold 
to  the  opinion  that  the  injury  produces  in  the  tissues  a  local 
change  (of  the  nutrition  or  otherwise)  which  prepares  the  field 
for  the  active  cause  of  the  growth.  Cohnheim's  adherents  are 
positive  that  it  is  impossible  for  a  cancerous  growth  to  follow 
an  injury,  unless  the  essential  tumor-iuatrix  is  present.     On  the 


MALIGNANT  TUMORS  509 

Other  hand,  the  advocates  of  the  parasitic  theory  are  equally 
certain  that  there  must  be  an  abrasion  which  opens  the  way 
to  infection. 

Certainly  many  of  the  leading  clinicians  are  agreed  that 
traumatism  is  at  least  a  predisposing  cause  of  cancer. 

In  this  connection  it  is  weU  to  remember  that  the  closest 
observers  consider  cicatrices,  benight  epithelial  grozvths,  ulcers 
(especially  tubercular),  epithelium  displaced  from  whatever 
cause,  and  chronic  intl animation  as  predisposing  causes  of  cancer. 

Heredity  Theory.  —  In  the  past  this  theory  had  many  fol- 
lowers, but  in  modern  times  it  has  become  less  popular.  Some 
investigators  have  been  led  to  consider  heredity  as  a  cause  of 
cancer  from  the  fact  that  (a)  cancer  sometimes  occurs  in  sev- 
eral succeeding  generations  of  the  same  family,  and  (b)  in 
some  instances  the  disease  attacks  the  same  organs  in  the  dif- 
ferent generations.  The  opponents  of  this  theory  cite  the  fact 
that  in  these  same  famiHes  many  members  escape  the  disease, 
and,  further,  that  there  are  many  instances  wherein  the  de- 
scendants of  persons  afflicted  with  cancer  were  not  so  affected. 
The  weight  of  authority  is  that  cancer  is  not  transmissible  from 
one  generation  to  another,  but  that  the  descendants  of  persons 
having  cancer  may  inherit  a  predisposition  to  the  same. 

The  most  famous  cases  which  have  been  cited  to  support 
the  heredity  theory  are  those  of  the  Bonaparte  family  and  the 
one  reported  by  Broca.  In  the  former,  history  shows  that 
Napoleon  Bonaparte  I,  his  father,  brother,  and  two  sisters 
died  from  cancer  of  the  stomach.  Broca's  case,  however,  is 
the  most  remarkable  and  complete  that  has  ever  been  pub- 
lished, viz. :  Madame  Z  died  of  cancer  of  the  breast,  leaving 
four  daughters,  A,  B,  C,  and  D,  all  of  whom  died  from  cancer 
of  the  breast  or  liver.  Madame  A  left  three  daughters  who 
were  all  living  at  an  advanced  age.  Madame  B  was  survived 
by  five  daughters  and  two  sons ;  one  son  escaped  the  disease, 
but  the  other  died  of  cancer  of  the  stomach,  and  all  five  sisters 
died  from  cancer  of  the  breast  or  liver.  Madame  C  gave  birth 
to  five  daughters  and  two  sons;  the  boys  were  not  afflicted 
with  cancer,  but  the  five  girls  died  from  cancer  of  the  breast, 
liver,  or  uterus.  Madame  D's  only  child,  a  son,  escaped  the 
disease.  The  first  daughter  of  Madame  C  was  survived  by  two 
sons  and  three  daughters,  one  of  the  latter  dying  from  cancer 
of  the  breast. 


610  DISEASES  OF  THE  RECTUM  AND  ANUS 

Age. — As  previously  intimated,  age  is  an  important  factor 
in  the  etiology  of  cancer.  It  is  universally  agreed  that  car- 
cinoma occurs  far  more  frequently  in  middle  life  and  old  age 
than  in  the  young;  but  authorities  have  been  unable  to  explain 
the  influence  which  seems  to  favor  the  development  of  the  dis- 
ease during  these  periods  of  life. 

Other  Influences,  which  are  said  to  favor  the  production  of 
cancer  are  climate,  location,  race,  sex,  occupation,  and  mental 
perversion,  all  of  which  have  been  discussed  in  the  general  re- 
marks on  the  disease.  Most  recently  it  has  been  claimed  that 
cancer  is  caused  by  eating  too  much  salty  meat,  and  that  the 
disease  is  caused  by  the  excess  of  salt  taken  into  the  system. 

The  Etiology  of  Sarcoma,  like  that  of  carcinoma,  has  not 
yet  been  fully  determined,  but  the  theories  already  given,  which 
have  been  advanced  to  explain  the  nature  and  cause  of  carci- 
noma, are  held  to  be  equally  applicable  to  sarcoma.  Sarcoma 
appears  to  support  Cohnheim's  theory  of  the  embryonic  origin 
of  neoplasms,  more  than  any  other  growth,  because  of  its  fre- 
quency in  infants  and  the  fact  that  it  often  has  its  origin  in 
moles,  nevi,  and  other  congenital  defects.  From  a  clinical 
stand-point,  however,  trauma  and  prolonged  irritation  seem  to 
be  important  factors  in  the  production  of  sarcoma.  Some  au- 
thorities claim  that  sarcoma  is  of  parasitic  origin ;  but  this  has 
not  been  proved,  and  the  weight  of  opinion  is  opposed  to  the 
theory. 

PATHOLOGY 

The  forms  of  cancer  common  to  the  ano-rectal  region 
are : — 

1.  Squamous-  (flat  pavement)  celled  carcinoma  (epithe- 
lioma). 

2.  Cylindric-  (columnar)  celled  (adeno-)  carcinoma. 
Squamous-celled  carcinoma  usually  originates  at  the  anus, 

but  may  involve  the  rectum.  It  is  extremely  rare,  and  is  less 
maHgnant  and  of  less  rapid  growth  than  the  cylindric-celled 
variety.  Cylindric-celled  carcinoma  may  be  located  in  any  part 
of  the  rectum.  It  is,  by  far,  the  most  common  malignant  neo- 
plasm occurring  in  this  region.  From  personal  experience  and 
an  analysis  of  the  statistics  of  others,  the  author  estimates  that 
approximately  95  per  cent,  of  these  growths  are  of  the  cylin- 
dric-celled (adenomatous)  variety  situated  within  the  rectum, 


MALIGNANT  TUMORS  511 

and  but  5   per  cent,  are  of  the  squamous-celled  (epitheliom- 
atous)  type  at  the  anus. 

Table  XVIII.     Location  of  the  Tumors  in  One  Hundred 
Cases  Examined  by  the  Author 

Ampulla    ■ 50  per  cent. 

Upper  rectum    20 

Upper  rectum   and   sigmoid 15 

Anal  canal   10 

Anus   (squamous-celled  variety) 5 

In  exceptional  cases  cyUndric-celled  cancer  may  originate 
at  the  anus,  and  epitheHoma  may  develop  in  the  mucosa  nor- 
mally covered  by  cylindric  epithelium.  Cadol  suggests  that, 
as  a  result  of  syphilis  or  proctitis,  the  ordinary  cylindric  epi- 
thelia  of  the  rectal  ampulla  may  be  changed  into  the  pavement 
variety,  and  that  this  may  account  for  the  occurrence  of  epithe- 
Homa within  the  bowel.  He  adds:  "For  these  reasons  the 
proportions  between  anal  and  ampullary  cancer,  on  the  one 
hand,  and  pavement-celled  and  cylindric-celled  cancer,  on  the 
other  hand,  do  not  coincide." 

Squamous-Celled  Carcinoma  (True  Epithelioma). — As  has  al- 
ready been  stated,  flat  or  pavement-celled  epithelioma  (Plate 
XXIX)  is  at  times  encountered  in  the  ano-rectal  region  and 
most  frequently  originates  at  the  muco-cutaneous  junction. 
This  form  of  carcinoma  is  somewhat  more  common  in  men 
than  in  women,  and  is  rarely  seen  in  persons  under  forty  years 
of  age. 

The  growth  in  the  anal  region  does  not  differ  materially 
in  appearance  or  histologic  formation  from  similar  growths 
attacking  the  skin  or  mucous  membrane  covered  with  squa- 
mous epithelia  in  other  parts  of  the  body. 

As  a  rule,  squamous  epithelioma  about  the  anus  progresses 
so  slowly  and  causes  so  little  disturbance  at  first  that  the  pa- 
tient is  unaware  of  the  existence  of  the  growth  for  several 
months.  In  exceptional  instances,  however,  the  growth  is 
more  rapid,  and  the  nature  of  the  disease  becomes  evident  in 
a  short  time. 

True  epithelioma  usually  begins  in  the  superficial  epitheha 
or  the  sudoriparous  or  sebaceous  glands,  but  it  may  originate 
in  a  fissure,  ulcer  (lupoid),  abrasion,  cicatrix,  wart,  or  other  new 
growth  or  psoriatic  patch  occurring  about  the  margin  of  the 
anus.  Gradually  it  manifests  itself  as  a  hard,  dry,  wart-like 
nodule,   or  as  an  ulcer  with  sharply-defined,  firm,   infiltrated 


512  DISEASES  OF  THE  RECTUM  AND  ANUS 

edges.  Ordinarily  it  is  of  the  former  variety,  and  does  not 
ulcerate  until  later  in  its  course.  The  growth  may  remain  su- 
perficial or  penetrate  into  the  deeper  structures,  destroying 
the  skin,  fascia,  muscle,  or  other  tissues  as  it  advances.  It 
sometimes  extends  upward  into  the  rectum,  involving  and  de- 
stroying the  mucosa  and  other  coats  of  the  bowel. 

Most  frequently,  however,  the  growth  attacks  the  skin  and 
spreads  to  the  perineum  and  scrotum,  or  commissure  of  the 
vagina  and  labia.  In  fact,  epithelioma  in  this  region,  as  in  other 
parts,  may  extend  without  limitation,  destroying  all  tissues 
as  it  spreads.  Sometimes  the  ulcerated  surface  is  fissured;  or 
it  may  be  covered  with  caulifiower-like  excrescences.  While 
the  ulcer  manifests  no  tendency  to  get  well,  healing  may  take 
place  on  one  side,  with  the  formation  of  glistening  scars,  the 
cell-proliferation  and  ulceration  continuing  in  another  direc- 
tion. When  not  completely  removed,  epithelioma  returns  at 
the  site  of  original  disease. 

The  superficial  variety  is  not  so  malignant  and  the  lym- 
phatics are  not  so  often  involved  as  in  the  deep-seated  type. 
In  either  form  of  the  disease  metastatic  deposits  are  delayed, 
but,  when  such  are  generated,  they  present  characteristics 
similar  to  those  possessed  by  the  parent-tissue.  Cadol  holds 
that  lymphatic  ganglia  already  infected  from  other  sources  are 
attacked  the  same  as  when  healthy. 

No  attempt  will  be  made  to  describe  in  detail  the  course 
of  epithelioma,  but  the  following  case  is  submitted  to  illustrate 
the  usual  progress  of  the  disease.  The  case  observed  was  that 
of  a  woman,  50  years  of  age,  in  whom  the  neoplasm  began  as  a 
small,  wart-like  growth  in  the  skin  outside  the  anus.  After  four 
months  it  broke  down,  forming  a  deep,  irregularly-shaped 
ulcer,  an  inch  (2.54  centimeters)  in  length,  three-fourths  of  an 
inch  (1.9  centimeters)  in  width,  extending  half  an  inch  (1.27 
centimeters)  into  the  rectum.  Its  edges  were  clearly  defined, 
not  unHke  those  of  a  chancre,  and  of  a  violaceous  hue.  Its  base 
was  uneven,  very  vascular,  and  bled  freely  from  slight  irritation. 
At  first  the  ulcer  was  not  sensitive,  and  exuded  a  sanious, 
purulent  discharge. 

A  diagnosis  of  epithelioma  was  made.  The  parts  were 
cocainized,  and  a  specimen  removed  and  delivered  to  a  com- 
petent pathologist.  After  a  careful  microscopic  examination 
of  the  tissue,  a  report  that  it  was  from  a  squamous-celled  car- 


MALIGNANI  TUMORS  513 

cinoma  was  received.  A  radical  operation  was  advised,  but 
was  declined.  The  patient  was  not  again  seen  by  the  author 
for  about  ten  months. 

During  this  time  the  growth  had  progressed  rapidly,  and 
the  patient  was  in  a  terrible  condition  when  she  returned.  She 
declared  herself  willing  to  undergo  any  operation  for  relief. 
The  growth  had  extended  almost  completely  around  the  anus 
and  up  into  the  rectum  for  a  distance  of  about  two  inches 
(5.08  centimeters),  destroying  the  mucous  and  muscular  coats 
of  the  anterior  two-thirds  of  the  bowel.  It  had  eaten  deeply 
into  the  perineum  and  through  th?  recto-vaginal  septum,  form- 
ing a  fistulous  sinus,  which  easily  permitted  the  introduction 
of  the  index  finger.  Both  the  internal  and  the  external  sphinc- 
ters were  destroyed,  and  the  patient  suffered  from  complete 
incontinence.  The  discharge  was  profuse,  purulent  in  char- 
acter, and  tinged  with  blood.  There  were  two  other  fistulous 
sinuses  opening  upon  the  buttocks,  and,  as  a  result  of  constant 
bathing  in  the  irritating  discharge  from  the  ulcerated  surface 
and  fistulas,  the  skin  for  several  inches  about  the  anus  was  very 
much  discolored  and  excoriated.  The  mucous  membrane 
above  was  highly  inflamed,  and  the  entire  rectum  immovable 
as  a  result  of  the  prolonged  perirectal  inflammation  excited 
by  the  disease.  There  was  more  or  less  bleeding  during  and 
after  defecation,  and  on  one  or  two  occasions  there  had  been 
almost  fatal  hemorrhage. 

The  patient  suffered  constantly  from  excruciating  pain  in 
the  bowel,  and  also  from  pain  reflected  up  the  back  and  down 
the  limbs.  Suffering  was  greatly  aggravated  during  defecation 
and  for  some  time  afterward.  In  addition,  she  complained 
bitterly  of  incessant  pruritus,  due  to  the  chafing  of  the  parts 
caused  by  the  discharge. 

The  inguinal  glands  were  enlarged,  but  there  was  no  evi- 
dence of  metastasis  in  distant  organs.  Loss  of  sleep,  constant 
suffering,  and  the  exhausting  discharge  had  produced  much 
emaciation,  with  a  loss  of  over  thirty-five  pounds.  The  im- 
possibility of  complete  removal  of  the  growth  led  the  author 
to  refuse  a  radical  operation  and  to  advise  a  colostomy.  This 
the  patient  consented  to  undergo,  and  two  days  later  an  arti- 
ficial anus  was  established  in  the  left  inguinal  region.  For  sev- 
eral weeks  following  the  operation  the  patient's  suffering  was 
greatly  alleviated  and  she  gained  considerable  in  weight.    Dur- 

33 


614  DISEASES  OF  THE  RECTUM  AND  ANUS 

ing  this  time  the  growth  progressed  slightly,  but  after  three 
months  it  began  to  extend  more  rapidly,  and  two  years  after 
the  writer  first  saw  the  case  the  patient  died  of  exhaustion. 

As  regards  the  histology  of  squamous-celled  carcinomata, 
the  superficial  type  is  made  up  of  small,  epithehal  cells,  and  the 
deep-seated  growth  of  large,  flat,  and  small  cells.  In  this  form 
of  epithelial  cancer  the  masses  of  cells  which  extend  from  the 
superficial  epidermis  into  the  deeper  structures  often  assume 
a  concentric,  or  onion-like,  arrangement,  forming  epithelial 
pearls  (Plate  XXIX).  The  stroma  of  connective  tissue  is 
scanty;    the  alveoli,  very  large. 

In  discussing  the  squamous-  or  pavement-  celled  carci- 
noma Ziegler  says :  "The  flat-celled,  epithelial  cancer  is  char- 
acterized by  the  formation  of  relatively  large  strings  of  cells 
of  irregular  shape;  but  besides  these  there  are  often  small 
strings  of  cells,  especially  in  those  cases  in  which  the  cancerous 
growth  has  begun  to  involve  the  larger  areas  of  the  mucous 
membrane.  The  epithelial  cells  which  are  massed  together  in 
separate  collections  still  show  plainly  the  character  of  the 
laminated,  flattened  epithelium;  but,  in  consequence  of  their 
growth  and  multiplication  within  the  interstices  of  the  tissues, 
they  generally  assume  a  variety  of  shapes  and  no  longer  mani- 
fest their  typic  characteristics.  Very  often  the  formation  of 
keratohyalin  and  the  change  into  a  horny  condition  take  place 
deep  down  in  the  center  of  the  large  epithelial  plugs ;  and 
along  with  the  process  of  hornification  the  cells  arrange  them- 
selves in  laminae  like  those  of  an  onion.  These  rounded  masses 
of  laminated,  horny  epithelium  are  called  epithelial  pearls,  or 
horny  bodies;  and  hence  the  name  horny  cancer  has  been  applied 
to  such  a  tumor." 

Cylindric-  (Columnar)  Celled  Carcinoma  (Adenocarcinoma,  In- 
filtrating Adenoma,  Adenoma  Destruens.  —  Owing  to  the  fre- 
quency with  which  it  occurs  in  this  region  and  its  extremely 
malignant  nature,  columnar-  or  cylindric-  celled  carcinoma  is 
one  of  the  most  important  diseases  encountered  in  the  rectum, 
and  the  most  difficult  with  which  the  surgeon  has  to  contend. 

In  its  incipiency,  cylindric-celled  carcinoma  of  the  rectum 
bears  a  close  resemblance  to  adenoma  in  that  it  produces  in  its 
growth  gland-like  formations  histologically  related  to  the  nor- 
mal epithelial  structures  of  the  bowel.  Moreover,  simple  ade- 
noma in  the  intestine  frequently  undergoes  a  clear  transition 


EXPLANATION  OF  PLATE  XXXI 


Above  is  a  papillar  adenomatous  growth  starting  on 
the  right  from  the  normal  raucous  membrane.  The 
papillar  growth  does  not  infiltrate,  but  on  the  left  the 
surface  becomes  ulcerated  and  there  is  infiltration : 
first  into  the  submucous  tissue,  farther  on  into  the  inner 
circular  muscular  coat,  while  at  one  point  below  this 
the  outer  longitudinal  muscular  coat  is  penetrated 
throughout  its  breadth  by  the  malignant  growth,  which 
reaches  as  far  as  the  submucous  tissue. 


PLMTE  XXXI 


.-'■:%J: 


'    \    i 


Carninnma  of  the  REctum,     [MagniRcatian,  B,J 


MALIGNANT  TUMORS  515 

into  carcinoma.  For  these  reasons  cylindric-celled  carcinoma 
is  often  described  as  adenocaycinoma  (Plate  XXX). 

This  variety  of  carcinoma  may  be  of  slow  or  rapid  growth, 
and  vary  in  shape,  size,  and  consistence.  In  regard  to  location, 
cylindric-celled  carcinoma  is  encountered  more  frequently  in 
the  anterior  and  posterior  than  in  the  lateral  walls  of  the  rec- 
tum. Cylindric-  or  columnar-  celled  carcinoma  in  the  rectum 
originates  in  the  mucous  membrane  in  the  tubular  glands  or 
the  crypts  of  Lieberkiihn. 

The  epithelial  cells  of  these  structures  multiply  rapidly. 
The  newly-formed  cells  vary  in  size,  but  are  usually  larger 
than  the  normal,  have  single  or  multiple  nuclei,  and  may  be 
arranged  in  one  or  more  layers.  As  a  result  of  this  increased 
cell-proliferation,  the  glands  become  dilated  and  irregular  in 
shape,  the  membrana  propria  disappears,  and  branching  tu- 
bules, lined  with  simple  or  atypic  epithelia,  arranged  in  one  or 
several  layers,  extend  into  the  submucosa  and,  in  time,  into 
the  musculature  (Plate  XXXI)  and  serosa,  converting  these 
into  neoplastic  tissue.  There  is  also  an  increased  reactive 
formation  of  connective  tissue  about  the  newly-formed  tubules 
which,  when  abundant,  gives  to  the  neoplasm  a  greater  or  less 
degree  of  firmness.  Those  neoplasms  in  which  the  connective- 
tissue  development  or  stroma  preponderates  are  less  rapid  in 
growth  and  invade  surrounding  parts  more  slowly  than  when 
the  epithelial  elements  predominate. 

The  resemblance  of  the  newly-formed  tubules  to  the 
healthy  glands  of  the  bowel  may  persist, — that  is,  their  lumina 
remain  distinct,— and  the  lining  epithelium  closely  resembles 
the  normal  cylindric  epithelium  of  the  intestine,  constituting 
typic  glandular  carcinoma,  or  so-called  malignant  adenoma, 
adenoma  destruens.  On  the  other  hand,  in  the  atypic  form  of 
the  growth,  which  is  most  common,  the  epithelium  is  un- 
natural and  the  lumina  of  the  newly-formed  tubules  completely 
obliterated  by  the  rapidly-proliferating  cells. 

The  extension  of  cylindric-celled  carcinoma  of  the  rectum 
may  occur  in  two  ways:  "1.  Throughout  the  entire  bulk  of 
the  tumor  by  proliferation  of  cancerous  elements.  2.  At  the 
margin  by  transformation  of  the  healthy  mucosa  into  neoplastic 
tissue. 

"In  the  first  type  of  increase  the  epithelial  elements  un- 
dergo direct  or  indirect  division.    Each  tube  increases  in  length 


516  DISEASES  OF  THE  RECTUM  AND  ANUS 

and  thickness.  At  the  same  time  new  tubes  are  given  off,  either 
outwardly  into  the  stroma  or  inwardly  into  the  lumen  of  the 
tube.  This  sort  of  new  formation  occurs  in  the  submucosa 
where  the  smooth  muscle-fibers  offer  a  resisting  wall,  which 
opposes,  for  a  long  time,  the  cancerous  invasion. 

"The  transformation  of  the  healthy  mucous  membrane 
into  neoplastic  tissue  is  not  so  easy  to  recognize.  At  first  the 
number  of  goblet-cells  in  the  mucosa  is  increased.  Tubes  are 
formed  which  are  sinuous  and  irregular.  The  cells  which  line 
the  tubes  are  at  first  augmented  in  height,  are  arranged  in 
strata,  with  increase  in  the  number  of  nuclei ;  the  zone  of  trans- 
formation is  abrupt;  often  but  two  or  three  cells  constitute  the 
interval;  that  is,  between  a  cell  of  the  cancerous  type  and  a 
normal  cell  there  may  be  but  two  thicknesses  of  indifferent 
cells.  In  many  cases  a  zone  of  transformation  can  hardly  be 
recognized. 

"Soon  in  the  course  of  its  evolution  the  cylindric  epithe- 
lium ulcerates  through  the  mucosa.  This  process  may  occur  in 
3.  twofold  manner:  1.  The  mucosa  ulcerates  by  reason  of 
transformation  into  cancerous  tissue  and  thus  disappears.  2. 
Inflammatory  foci  develop  about  the  spreading  cancerous  tis- 
sue of  the  submucosa,  destroying  the  superjacent  mucosa." 
(Cadol.) 

When  examined  early,  the  gross  appearance  of  a  cylindric- 
celled  carcinoma  of  the  rectum  is  that  of  a  small,  movable, 
rounded  or  flattened  indurated  swelling,  with  elevated  center, 
in  the  submucosa.  As  it  increases  in  size,  the  neoplasm  involves 
and  becomes  inseparable  from  the  mucous  and  muscular  tunics 
of  the  bowel.  The  neoplasm  may  extend  in  any  direction,  and 
from  the  form  it  assumes  may  be  classed  as :  (a)  anitnlar,  (b) 
tubular,  or  fc)  protuberant  cancer. 

Because  of  the  arrangement  of  the  blood-vessels  and  lym- 
phatics around  the  bowel,  columnar-celled  carcinoma  not  in- 
frequently grows  more  rapidly  in  the  lateral  than  in  the  vertical 
direction,  and  in  time  partially  or  completely  encircles  the  gut 
in  the  form  of  a  firm  band  of  neoplastic  tissue,  from  one-fourth 
to  one-half  inch  (0.64  to  1.27  centimeters)  in  thickness.  When 
the  carcinomatous  belt  does  not  exceed  one  inch  (2.54  centi- 
meters) in  width,  it  is  designated  annular  (ring),  and  when  it 
involves  several  inches  of  the  rectum,  converting  the  gut  into 
a  rigid  tube,  tubular  (laminar)  carcinoma.     The  former  is  more 


MALIGNANT  TUMORS  517 

common  in  the  upper  rectum  and  sigmoid,  and  the  latter  is 
more  frequently  situated  lower  down.  Again,  the  carcinom- 
atous growth  may  at  first  be  present  beneath  the  mucosa  as 
single  or  multiple  ovoid,  hard  nodules,  which  increase  in  size 
until  they  project  into  the  lumen  of  the  bowel  as  smooth  or 
irregular,  hard  or  moderately  soft  tumor-masses — protuberant 
(tuberous)  carcinoma, — to  which  the  mucosa  is  firmly  adherent. 

These  tumor-masses  are  Jiard  or  soft,  depending  upon  the 
predominance  of  the  stroma  or  epithelial  elements,  respectively. 
They  not  infrequently  blend,  forming  one  or  more  neoplasms 
of  enormous  size.  The  growth  is  seldom  confined  to  the  bowel. 
Indeed,  it  may  extend  in  any  direction  and  attack  neighboring 
organs  or  the  sacrum  or  coccyx.  When  it  breaks  down  and 
ulcerates,  fistulous  sinuses  of  sufficient  size  to  permit  the  dis- 
charge of  feces  may  form  between  the  rectum  and  the  bladder, 
urethra,  or  vagina. 

As  has  already  been  stated,  the  existence,  rapidity  of 
growth,  and  degree  of  malignancy  of  cylindric-celled  carcinoma 
of  the  rectum  depend  largely  upon  the  proportion  of  connective 
tissue  within  the  tumor.  When  this  tissue  is  in  excess,  the 
neoplasm  is  harder,  less  malignant,  and  increases  less  rapidly 
than  when  the  stroma  is  delicate  and  the  epithelial  constituents 
predominate. 

Ulceration  and  diminution  of  the  lumen  of  the  bowel  occur 
sooner  or  later  in  nearly  all  cases  of  columnar-celled  carcinoma 
of  the  intestine.  The  ulceration  may  be  superficial  or  deep  and 
occur  in  an  early  stage  of  the  disease  or  not  until  a  later  period 
in  its  course.  Again,  there  may  be  but  one  ulcer  or  a  number 
of  ulcerated  areas  separated  by  apparently  healthy  mucosa. 
In  the  constricting  or  annular  and  tubular  forms  of  cancer  the 
ulceration  is  not  so  deep  as  in  the  protuberant  variety.  In  the 
latter  the  ulcerative  process  extends  deeply  into  the  tumor- 
formations  and  imparts  to  the  ulcers  a  pimched-out,  or  crater- 
like, appearance,  readily  recognized  on  digital  exploration. 

The  ulceration  encroaches  upon  the  blood-vessels,  caus- 
ing hemorrhage,  which  may  be  slight  or  profuse,  according  to 
the  size  of  the  vessels  involved.  The  discharge  from  the  ulcer- 
ated surfaces  is  abundant,  irritating,  and  very  ofifensive ;  it  pro- 
duces excoriations  of  the  mucosa  and  skin  about  the  anus,  and, 
if  allowed  to  accumulate,  gives  rise  to  the  formation  of  ab- 
scesses and  fistulous  sinuses. 


518  DISEASES  OF  THE  RECTUM  AND  ANUS 

The  obstruction  caused  by  rectal  cancer  may  be  either  par- 
tial or  complete. 

True  carcinomatous  stricture  is  produced  in  the  bandular 
(annular  and  tubular)  forms  as  a  result  of  the  increased  forma- 
tion and  contraction  of  dense,  fibrous  tissue,  which  constricts 
and  puckers  the  gut-wall.  Some  of  the  stenosis  may  be  due 
to  cicatrization  following  partial  healing  of  the  ulcers.  In  the 
protuberant  variety  of  rectal  carcinoma  the  diminution  of  the 
lumen  of  the  bowel  may  be  caused  partially  by  the  increased 
formati'on  and  contraction  of  fibrous  connective  tissue;  but 
the  obstruction  is  caused  principally  by  the  projection  of  the 
tumor-masses  into  the  intestine,  which,  according  to  Quenu, 
causes  the  gut  to  twist  and  deviate  in  its  course. 

In  cancerous  disease  of  the  rectum  the  mucosa  over  the 
growth,  when  not  ulcerated,  is  usually  congested.  The  super- 
ficial veins  sometimes  become  dilated  (sympathetic  hemor- 
rhoids) as  a  result  of  pressure.  Again,  the  mucous  membrane 
may  be  dotted  over  with  benign  vegetations,  owing  to  the  ulcer- 
ation and  consequent  irritating  discharge,  or  there  may  be 
present  about  the  neoplasm  larger  cauliflower-like  protuberances 
which  eventually  become  a  part  of  the  central  growth.  The 
excrescences  frequently  become  detached  during  defecation 
and  cause  more  or  less  bleeding. 

Rectal  carcinoma  may  remain  localized  or  become  dis- 
seminated. In  the  latter  case  metastatic  deposits  producing  the 
same  type  of  neoplasm  as  the  parent-tumor  occur  in  neighbor- 
ing lymph-nodes  and  organs.  In  cylindric-celled  carcinoma  of 
the  rectum  the  retroperitoneal,  sacral,  and  lumbar  nodes  are 
attacked.  In  the  squamous-celled  variety  of  carcinoma  (true 
epithelioma),  which  is  located  at  the  anus,  the  inguinal  nodes  are 
first  involved. 

Owing  to  the  predominance  of  the  cells  or  stroma,  the 
changes  occurring  within  them,  and  the  fact  that  they  may  be 
pigmented,  rectal  carcinomata  are  sometimes  distinguished  as 
(a)  medullary,  (b)  scirrJius,  (c)  colloid,  and  (d)  melanotic  carci- 
noma. While  these  neoplasms  differ  in  their  microscopic  and 
macroscopic  appearance,  tliey  are  not,  in  the  zvriters  opinion,  to 
he  regarded  as  distinct  varieties  of  carcinoma,  as  was  formerly 
done,  but  should  be  considered  as  varying  types  depending 
upon  environment,  conditions  of  nutrition,  degenerative 
chan^-es.  etc. 


MALIGNANT  TUMORS  519 

Medullary  Carcinoma  (soft  or  encephaloid  carcinoma)  is 
characterized  by  an  abundance  of  epithelial  cells  and  a  slight 
amount  of  stroma.  This  form  of  carcinoma  is  poorly  supplied 
with  blood-vessels,  is  pale  in  color,  and  presents  slight  resem- 
blance to  brain-substance;  for  the  latter  reason  it  is  sometimes 
called  encephaloid  cancer.  When  the  growth  is  very  vascular, 
it  has  been  designated  as  carcinoma  teleangiectodes.  Medullary 
cancer  is  quite  common  in  the  rectum.  It  is  of  rapid  growth, 
very  malignant,  and  soft,  vascular,  and  juicy.  It  increases  rap- 
idly, sometimes  attaining  enormous  proportions,  completely 
filling  the  pelvis.  It  involves  the  lymphatics  early  and  returns 
speedily  after  operation  when  every  vestige  of  the  growth  has 
not  been  removed. 

By  scraping  or  squeezing  the  cut  surface  of  the  growth, 
considerable  "cancer-milk"  (juice)  can  be  expressed.  This 
consists  of  fatty-degenerated  cell-nests,  which  when  placed  in 
water  give  to  it  a  milky  aspect.  Owing  to  the  fact  that  the 
cells  are  so  numerous  and  so  closely  crowded  together  in 
medullary  cancer,  it  is  often  extremely  difficult  to  demonstrate 
the  stroma  by  either  a  microscopic  or  macroscopic  examination 
of  the  growth. 

Scirrhous  Carcinoma  (fibrocarcinoma,  or  hard  cancer)  is 
recognized  by  the  preponderance  of  the  connective  tissue,  the 
comparatively  few  epithelial  cells  contained  within  the  alveoli, 
and  the  tendency  of  the  cells  to  degenerate  early.  Hard  cancer 
may  start  as  such,  or  it  may  be  soft  at  first  and  gradually  be- 
come more  dense  as  the  stroma  increases  and  the  cells  perish. 
In  regard  to  this  point  Ziegler  says :  "A  cancer  which  zvas 
originally  soft  may  become  hard;  that  is,  as  the  induration  of  the 
connective  tissue  advances,  the  cancerous  portions  undergo  a  corre- 
sponding shrinkage.  Cancers  of  the  breast  or  stomach  or  intes- 
tine often  undergo  such  secondary  induration;  so  that  the 
nests  of  cancer-cells  may  be  wholly  wanting  in  the  tissues  which 
have  undergone  this  fibrous  change." 

Scirrhus,  or  "hard  cancer,"  occurs  most  frequently  at  the 
recto-sigmoidal  juncture  and  on  the  anterior  rectal  zvall  op- 
posite the  prostate.  It  is  of  slow  growth,  less  mahgnant  than 
the  medullary  form,  and  when  removed  very  little  cancer-juice 
can  be  expressed  from  it  on  incision.  It  produces  a  creaking 
noise  when  incised,  is  tough,  and  has  a  cartilaginous,  or  raw- 
potato-like,  appearance  on  section.     It  may  be  bandular  or 


530  DISEASES  OF  THE  RECTUM  AND  ANUS 

nodular,  and  in  exceptional  cases  it  may  be  hard  in  one  place 
and  soft  in  another.  It  is  not  very  vascular,  and  breaks  down 
and  ulcerates  less  frequently  than  soft  cancer. 

Colloid  Carcinoma  (alveolar,  mucoid,  gelatinoid,  or  glutinoid 
cancer)  consists  of  large  alveoH  (macroscopic),  which  are 
filled  with  cells  and  mucoid  or  colloid  material  (Plate  XXXII). 
This  variety  of  carcinoma,  which  may  be  of  large  or  small 
dimensions,  is  occasionally  met  with  in  the  rectum.  It  is  soft, 
not  very  malignant,  and  sometimes  remains  stationary  for  a 
considerable  time.  It  ulcerates  slowly,  and  does  not  readily 
cause  infection  of  the  lymphatics.  It  does  not  always  recur 
after  excision.  Owing  to  degeneration,  or  possibly  to  secre- 
tion from  the  connective  tissue,  the  alveoli  are  filled  with  a 
jelly-like  material,  mucoid  or  colloid  in  character,  together  with 
comparatively  few  cells,  which  may  eventually  degenerate  and 
entirely  disappear.  As  the  gelatinoid  material  accumulates  and 
distension  increases,  the  walls  between  the  alveoli  are  broken 
down  and  cavities  (alveoli)  of  greater  (macroscopic)  size  are 
formed.  This  feature  has  led  some  surgeons  to  designate  this 
form  of  growth  as  alveola}-  carcinoma  (cancer).  The  gelatinoid 
contents  appear  in  the  center  of  the  cell-nests  between  the  cells, 
or  between  the  stroma  and  the  cells  in  the  form  of  diminutive 
droplets,  which  blend  and  form  larger  collections.  There  seems 
to  be  some  difference  of  opinion  whether  this  transparent,  jelly- 
like material  is  elaborated  by  the  beaker  cells,  exuded  by  the 
vessels,  or  is  formed  by  the  stroma.  In  the  later  stages  of 
colloid  cancer  considerable  quantities  of  this  substance  is  evac- 
uated with  the  stools. 

Melanotic  Carcinoma  ("Black  Cancer")  is  distinguished  by 
its  dark  color,  which  is  due  to  the  deposit  of  granules  of  dark 
or  brdzvn  pigment  within  the  cells  and  sometimes  in  the  stroma. 
Melanotic  carcinoma  is  soft,  fairly  vascular,  and  extremely 
malignant.  It  is  inclined  to  ulcerate  early  and  to  lead  to  con- 
siderable bleeding,  and  is  accompanied  by  a  very  offensive  dis- 
charge, which  is  sometimes  discolored  by  the  pigment.  This 
variety  of  carcinoma  is  rare  in  the  human  subject,  but  is  not 
infrequently  encountered  in  the  horse.  It  very  probably  be- 
longs to  the  sarcomata  (page  523). 

The  author  knows  of  but  one  published  case  of  ossifying 
carcinoma  of  the  rectum,  namely :  the  one  recorded  bv  Wag- 
staffe.    In  this  case  the  neoplasm  was  of  considerable  size,  nod- 


EXPLANATION  OF  PLATE  XXXII 


Metastatic  deposits  in  lymph-node  from  carcinoma  of 
rectum.  The  small  black  spots  are  the  nuclei  of  the 
lymph-cells,  representing  the  original  tissue  of  the  node. 

The  protoplasm  of  the  infiltrating  carcinoma-cells  is  * 
pale  and  swollen,  containing  much  colloid  material,  the 
nuclei  being  relatively  small  and  in  many  instances  dis- 
placed toward  the  periphery  of  the  cell.     In  some  cells 
the  nucleus  has  entirely  disappeared. 


FLUTE  XXXII 


Metastatic  JjEpnsitin  Lymph-nnde  from  Calloiti  Carcinoma  of  the  Rectum, 
[Magnificatinn,  250,] 


MALIGNANT  TUMORS  521 

ular,  and  when  incised  was  found  to  contain  several  sharp- 
pointed  pieces  of  bone.  The  growth  had  no  connections  with 
the  sacrum,  coccyx,  or  other  bony  structures  of  the  pelvis. 

Sarcoma, — Sarcoma  rarely  occurs  in  the  rectum,  and  in  this 
region  of  the  body  attacks  men  much  more  frequently  than 
women  (Plate  XXXIII).  It  is  unquestionably  a  disease  of 
adult  life,  though  in  the  young  it  is  more  common  than  other 
malignant  neoplasms.  The  ages  at  which  intestinal  sarcoma 
is  most  frequent  is  shown  by  Boas's  analysis  of  Kruger's 
statistics,  viz : — 

Table  XIX.     Frequency  of  Intestinal  Sarcoma  in  Different  Decades 
3  cases  in  the  first  decade. 

3  cases  in  the  second  decade. 
6  cases  in  the  third  decade. 

10  cases  in  the  fourth  decade. 

5  cases  in  the  fifth  decade. 

6  cases  in  the  sixth  decade. 

4  cases  in  the  seventh  decade. 

37 

Table  XX.     Location  of  Intestinal  Sarcoma  in  Thirty-seven  Cases 

Small  intestine   16 

Ileum  and  cecum   

Cecum    

Vermiform  appendix  

Transverse  colon 

Small  and  large  intestine 

Rectum     16 

37 

The  classification  and  description  of  the  various  forms  of 
sarcomata  are  very  clearly  and  concisely  given  by  the  writer's 
colleague.  Prof.  H.  T.  Brooks,^  as  follows:  "According  to  the 
nature  of  the  matrix — i.e.,  the  species  of  connective  tissue — 
from  which  the  sarcoma  proceeds  are  distinguished :  iibro-, 
myxo-,  glio-,  melano-,  chondro-,  and  osteo-  sarcomata;  according 
to  the  consistence,  which  is  principally  dependent  upon  the 
richness  and  character  of  the  intercellular  substance,  the  soft 
and  the  hard;  according  to  the  size  of  the  cells,  the  small-celled 
and  the  large-celled  sarcomata.  Sarcoma  medullare  consists  prin- 
cipally of  cells,  and  contains  only  a  small  amount  of  inter- 

'^  Translation  of  Langerhans's  "Essentials  of  Pathologic  Histology,"  F.  A.  Davis 
Company,  Philadelphia,  Pa. 


522  DISEASES  OF  THE  RECTUM  AND  ANUS 

cellular  substance.  The  cells  in  all  sarcomata  are  derived  from 
the  cells  of  the  connective  substances,  but  they  frequently 
reach  a  higher  state  of  development.  According  to  the  shape 
of  the  cells  are  distinguished:  round-celled  sarcoma  (sarcoma 
glohocellulare),  spindle-celled  sarcoma  (sarcoma  fusocellulare), 
reticular-celled  sarcoma  (sarcoma  reticulare).  Sarcoma  giganto- 
celhdare  (giant-celled  or  myelo-  sarcoma)  is  distinguished  by  the 
occurrence  of  numerous  multinuclear  giant  cells.  In  all  sar- 
comata the  cells  are  separated  by  more  or  less  (frequently  very  little, 
scarcely  recognizable)  intercelhdar  substance.  In  consequence  of 
this  it  occasionally  happens  that  the  giant  cells  present  in  a 
tumor  possess  a  certain  similarity  to  cancer-alveoli.  There  are 
also  true  mixed  forms  (carcinoma  sarcomatodes),  in  which 
certain  areas  have  a  purely  sarcomatous,  others  a  carcinoma- 
tous, structure. 

"The  intercellular  substance  of  the  sarcomata  is  seldom 
pure  connective,  glue-yielding  tissue;  it  often  contains  albu- 
minous and  mucinous  constituents ;  so  that  granular  precipita- 
tions originate;  it  may  be  homogeneous  (in  myxosarcoma), 
granular  (in  gliosarcoma),  or  fibrillar. 

"Sarcomata  with  a  highly-vascular  structure  (sarcoma 
teleangiectodes)  manifest  a  decided  tendency  to  hemorrhages 
(sarcoma  hcemorrhagicum) .  Sarcoma  diffusum  penetrates  quite 
equally  an  organ  or  a  part  of  an  organ  in  the  form  of  an  in- 
filtration, while  sarcoma  tuberosum  is  the  common  tumor-form. 
Sarcoma  fungosum  spreads  over  the  surface  in  the  form  of  a 
fungus,  with  projecting  margins;  sarcoma  polyposum  resembles 
in  its  exterior  conformation  an  ordinary  polyp." 

Almost  any  type  of  sarcomata  may  be  encountered  in  the 
ano-rectal  region,  viz. :  the  soft  and  the  hard,  small  and  large 
round-celled,  small  and  large  spindle-celled,  medullary,  mela- 
notic, cysto-,  and  lympho-  sarcomata.  In  most  instances  sar- 
comatous growths  of  the  rectum  are  of  the  small,  round-celled 
variety,  though  a  few  cases  of  spindle-celled  sarcomata  have 
been  reported  as  occurring  in  this  region. 

The  small-celled  sarcoma  is  usually  soft,  of  more  rapid  de- 
velopment, and  more  malignant  than  the  large-celled  variety. 
The  rapidity  of  the  growth  of  these  tumors  depends  principally 
upon  the  vascular  supply  and  the  amount  of  the  fibrous-tissue 
constituent ;  when  these  are  abundant,  the  tumors  are  of  slow 
growth  (Plate  XXXIV),  and,  when  scanty,  growth  is  more 


EXPLANATION  OF  PLATE  XXXIII 


The  photograph  shows  the  inner  muscTilar  coat  of 
the  rectum  infiltrated  by  round  sarcoma-cells,  with  in- 
tensely hyperchromatic  nuclei  and  relatively  small 
amount  of  protoplasm.  The  fusiform  cells  with  elon- 
gated nuclei  are  the  involuntary  muscle-fibers,  somewhat 
compressed  and  atrophied  on  account  of  the  infiltration. 


FLUTE  XXXIH 


Sarcama  of  thB  REctam,     [Magnificatian,  25D.] 


MALIGNANT  TUMORS  523 

rapid.  When  the  tumor  is  poor  in  connective  tissue,  it  is  desig- 
nated as  medullary,  and,  when  it  is  hard  and  composed  princi- 
paHy  of  this  tissue,  it  is  designated  as  scirrJiiLs,^  or  hard  {sar- 
coma durum).    The  latter  are  usually  well-defined  tumors. 

Sarcomatous  tumors  may  ulcerate  or  undergo  fatty,  mu- 
coid, or  cheesy  degeneration  (coagulation  necrosis).  They  are 
usually  single,  but  in  rare  cases  may  be  multiple. 

Sarcomata  of  the  rectum  may  develop  in  the  subserosa, 
mucosa,  or  submucosa;  but  in  the  majority  of  instances  they 
originate  in  the  latter,  and  may  extend  into  the  mucous  mem- 
brane, but  more  frequently  spread  outward  and  deeply  into 
the  perirectal  structures. 

Lymphosarcoma  deserves  special  mention  because  it  is  so 
different  in  location  and  structure  from  the  other  forms  of  sar- 
coma. This  variety  of  sarcoma  is  characterized  by  the  manner 
in  which  it  attacks  lymphatic  structures.  Depending  upon  the 
amount  of  connective  tissue  present,  the  growth  may  be  hard 
or  soft,  but  usually  the  latter.  Lymphosarcoma,  as  the  name 
indicates,  is  of  the  round-celled  type,  and  possesses  the  char- 
acteristics of  lymphatic  glandular  tissue.  While  the  growths 
may  be  encountered  in  other  localities,  they  most  frequently 
develop  in  the  lymphoid  tissue  of  the  submucosa.  In  the  intes- 
tine, they  may  originate  at  any  point,  the  rectum  being  one  of 
the  favorite  sites.  They  appear  as  incapsulated,  smooth,  elas- 
tic tumors,  which  begin  in  a  single  lymph-nodule  and  attack 
one  node  after  another  until  all  of  the  glands  of  the  affected 
region  have  been  displaced  by  the  neoplastic  tissue.  It  is  only 
a  question  of  time  until  the  disease  is  carried  to  distant  parts, 
mainly  through  the  lymph-channels,  resulting  in  the  formation 
of  tumors  having  the  same  lymphadenoid  appearance  as  the 
primary  growth.  Eventually  the  capsule  is  destroyed  and  the 
growth  involves  adjacent  structures.  Under  favorable  circum- 
stances it  breaks  down  and  ulcerates. 

Melanotic  Sarcoma  ("Black  Cancer"),  occurs  in  the  rectum 
more  frequently- than  in  other  parts  of  the  intestine,  but  even 
in  this  locality  it  is  extremely  rare.  The  author  has  observed 
but  two  cases  of  melanotic  sarcoma,  one  in  his  own  practice, 
and  a  second  with  Prof.  J.  P.  Tuttle,  of  New  York;  in  both 
the  disease  was  situated  at  the  anus,  and  had  attacked  the  skin 


^  In  a  strict  sense,  the  term  scirrhus  is  usually  applied  to  carcinoma.. 


524  DISEASES  OF  THE  RECTUM  AND  ANUS 

and  deeper  structures  to  a  considerable  extent,  while  the  mu- 
cosa was  but  slightly  involved.  Owing  to  the  ulceration,  indura- 
tion, and  general  resemblance  of  the  tumors  to  true  epitJie- 
liomata,  such  a  diagnosis  was  made  in  both  cases,  but  micro- 
scopic examination  of  portions  of  the  growths  proved  them  to 
be  melanotic  sarcomata.  Pigmented  sarcoma  is,  perhaps,  the 
most  maHgnant  of  the  sarcomatous  tumors,  and  regional  and 
general  dissemination  (metastases)  occur  early.  Ball,  of  Dub- 
lin, has  placed  on  record  a  most  remarkable  case  of  melanotic 
sarcoma  of  the  rectum.  The  largest  collection  of  cases  of 
melanotic  growths  of  the  rectum  has  been  made  by  M.  Nepveu^ 
of  Paris,  who  cites  ten  instances ;  five  of  these  were  shown  by 
microscopic  examination  to  be  melanotic  sarcomata.  In  fact^ 
but  very  few  cases  of  this  disease  have  been  reported. 

The  characteristic  clinic  manifestation  of  melanotic  sar- 
coma is  its  dark  color,  due  to  the  deposits  of  pigment  usually 
within  the  cells  composing  the  tumor.  When  the  growth  is 
located  within  the  rectum,  its  nature  is  sometimes  revealed  by 
the  presence  of  pigment  in  the  feces  or  on  the  examining  finger 
after  digital  exploration.  Such  an  occurrence,  however,  is  ex- 
ceedingly rare.  The  deposits  of  pigment  may  be  in  the  cells, 
intercellular  substance,  or  both. 


SYMPTOMS 

In  the  earlier  stages  of  malignant  disease  in  the  rectum 
the  symptoms  are  extremely  vague.  At  first  there  is  no  pain, 
bleeding,  discharge,  or  obstruction,  and  the  only  warning  the 
patient  receives  of  the  existence  of  trouble  in  the  rectum  is 
an  indescribable  sensation  of  uneasiness,  which  usually  occurs 
some  little  time  after  the  beginning  of  the  growth.  For  this 
reason  the  patient  is,  in  most  cases,  unable  to  give  an  intel- 
ligent idea  of  the  onset  of  the  malady.  As  the  disease  pro- 
gresses, the  sensation  described  shortly  gives  way  to  symptoms 
of  a  more  pronounced  character,  such  as  weight  and  fullness  in 
the  bowel,  or  in  the  pelvis,  when  the  growth  is  high  up.  At  this 
time  there  is  some  uneasiness  during  defecation  and  discom- 
fort in  the  sacro-coccygeal  region  and  sometimes  in  the  limbs, 
which  are  frequently  attributed  to  hemorrhoids,  fissure,  or 
sciatica.  These  manifestations  are  followed  by  a  frequent  de- 
sire to  stool,  or  a  sensation  of  something  in  the  bowel  which 


MALIGNANT  TUMORS  525 

it  is  impossible  to  expel,  and  defecation  becomes  less  frequent, 
prolonged,  and  difficult. 

Constipation  now  alternates  with  diarrhea.  Because  of 
the  frequent  desire  to  defecate  and  the  consequent  excessive 
straining,  the  liquid  and  semisolid  feces  are  discharged  around 
the  solid  fecal  mass,  which  is  retained  by  the  growth  until  soft- 
ened by  cathartics  or  washed  out  by  enemata.  Semisolid  feces 
are  discharged  in  the  form  of  long,  grooved,  fattened  or 
rounded,  pipe-stem-like  strings.  When  the  obstruction  is  high 
up  in  the  bowel,  fecal  matter  sometimes  collects  below  it,  and 
in  such  cases  the  dejecta  may  be  well  formed.  At  this  period 
the  growth  usually  commences  to  break  down  and  ulcerate, 
and  this,  together  with  the  irritation  of  the  retained  feces, 
excites  a  proctitis.  As  a  result  of  the  ulceration  and  the  inflam- 
mation, the  feces  are  now  discharged  mixed  with  mucus,  pus, 
and  blood,  the  amount  of  hemorrhage  being  slight  or  profuse, 
depending  on  the  extent  of  the  ulceration  and  the  size  of  the 
vessels  involved.  The  evacuations  sometimes  contain  portions 
of  the  growth  which  have  sloughed  off,  or,  in  the  colloid  va- 
riety, jelly-like  masses  may  be  voided.  When  the  cancer  is 
melanotic  in  character,  the  dejecta  may  be  dark  and  discolored 
with  pigment.  This  is  extremely  rare,  however.  The  dis- 
charge increases  greatly  in  amount,  and  not  infrequently  has 
an  extremely  foul  odor;  but  the  latter  is  a  symptom  of  less 
importance  than  some  writers  would  imply. 

Owing  to  the  irritating  discharge,  the  anal  margin  be- 
comes the  site  of  vegetations,  elongated  tags  of  skin,  and  ex- 
coriations, causing  a  most  intense  pruritus. 

When  the  rectum  is  not  kept  properly  cleansed  and  the 
discharge  is  allowed  to  accumulate,  abscess  and  Ustidous  sinuses 
are  formed  which  open  upon  the  external  surface  or  into  the 
bladder,  urethra,  or  vagina. 

Except  in  cases  where  the  cancer  is  located  at  the  anus 
or  an  extensive  ulceration  exists,  these  patients  experience 
but  little  pain  until  the  growth  encroaches  upon  the  nerves 
and  attains  such  size  as  to  produce  a  high  degree  of  obstruc- 
tion, at  which  time  suffering  becomes  intense.  They  complain 
of  constant  bearing-down  pains  and  a  never-ceasing  desire  to 
empty  the  bowel.  In  addition,  there  may  be  reflected  pain  in 
neighboring  organs  (especially  the  bladder)  or  down  the  limbs. 
The  irritating  discharge  produces  a  most  disagreeable  burning 


526  DISEASES  OF  THE  RECTUM  AND  ANUS 

sensation  in  the  lower  bowel,  and  the  retention  of  gases  above 
the  obstruction  gives  rise  to  very  distressing,  colicky-like  pains 
in  the  abdomen.  When  the  disease  extends  to  and  involves 
neighboring  organs  or  the  sacrum  and  coccyx,  the  pain  is  most 
excruciating.  In  cancer  of  the  anus,  involving  the  skin  and 
sphincter-muscle,  the  pain  is  constant,  and  much  more  severe 
than  when  the  growth  is  located  above  the  anal  canal. 

Important  symptoms  of  cancer  of  the  rectum  are  :  involve- 
ment of  the  lymphatic  glands,  metastasis  in  distant  organs,  loss 
of  appetite,  indigestion,  emaciation,  coprostasis,  paralytic  ileus, 
insomnia,  sallozu  complexion  (cachexia),^  vesical  disturbances, 
partial  obstruction,  dilatation  of  the  colon,  tympanites,  and 
chronic  peritonitis.  Some  of  the  rare  symptoms  and  compli- 
cations which  appear  late  in  the  course  of  the  disease  are: 
edema  of  the  legs,  when  the  iliac  veins  are  involved;  ascites, 
complete  obstruction,  fecal  vomiting,  rupture  or  perforation 
of  the  bowel,  embolism,  thrombosis,  uremia,  and  hydronephro- 
sis from  the  involvement  of  the  ureters. 

When  the  ulcerative  process  extends  rapidly,  it  may  result 
in  the  destruction  of  the  sphincters,  causing  complete  incon- 
tinence; in  perforation  of  the  intestine,  resulting  in  fecal  ab- 
scesses; or  the  septum  between  the  rectum  and  vagina,  blad- 
der or  urethra  may  be  destroyed  and  fistulous  sinuses  estab- 
Hshed  between  the  rectum  and  these  organs,  allowing  the  feces 
to  escape. 

Cancer  patients  eventually  die  of  complete  obstruction, 
exhaustion,  secondary  involvement  of  other  organs,  or  perforation 
and  septic  peritonitis. 

The  Symptoms  of  Sarcoma  are,  in  the  main,  similar  to  those 
of  carcinoma.  The  following  symptoms  are  peculiar  to  sar- 
coma, but  all  are  not  manifest  in  every  case : — 

Sarcomatous  tumors  are  commonly  globular,  oblong  or 
flattened,  extensive,  well-defined,  movable,  rapidly-developing 
growths  which  are  not  tender  to  the  touch  and  cause  but  little 
pain  until  they  reach  enormous  proportions.  Intestinal  steno- 
sis, obstruction,  and  fecal  impaction  occur  much  less  frequently 
in  sarcoma  than  in  carcinoma.  On  the  other  hand,  however, 
it  has  been  noted  that  sarcoma  is  very  often  marked  by  exten- 
sive dilatation  of  the  bowel.    Senn  says :   "A  sarcoma  produces 


1  Due  to  disturbance  of  nutrition,   owing  to   the   absorption   of  poisons  from   the 
ulcerated  cancer-surface  or  from  toxins  generated  within  the  growth. 


MALIGNANT  TUMORS  527 

intestinal  obstruction  either  by  the  tumor-mass  filling  the 
lumen  of  the  bowel,  by  invagination,  or  by  volvulus,  and  never 
by  cicatricial  contraction  as  is  so  often  the  case  in  circular 
carcinoma."  Ulceration  does  not  usually  occur  until  the  later 
stages  of  the  disease,  if  at  all,  and  causes  but  little  hemorrhage. 
Cachexia  develops  early,  and  metastasis  always  occurs  early  if 
the  growth  is  soft,  and  late  if  the  tumor  contains  an  abundance 
of  fibrous  tissue. 

Sarcomatous  disease  is  sometimes  accompanied  by  an 
irregular  temperature. 

In  conclusion,  this  form  of  malignancy  is  not  infrequently 
encountered  in  early  life,  and  in  many  instances  the  patient 
gives  a  history  of  a  previous  direct  injury,  such  as  a  blow  or 
contusion  at  the  site  of  the  growth. 

Metastasis.  —  In  carcinoma  or  sarcoma  of  the  rectum 
metastatic  deposits  in  distant  organs  are  often  formed  (Plate 
XXXV) :  sometimes  during  the  course  of  the  disease,  most 
frequently  at  a  late  period.  Rectal  carcinoma  usually  remains 
a  local  disease  for  a  considerable  time,  and  secondary  deposits 
are  not  formed  until  the  disease  is  far  advanced ;  in  very  many 
cases  metastasis  does  not  occur  at  all,  as  is  shown  by  the  fol- 
lowing statistics :  In  67  cases  of  fatal  carcinoma  of  the  rectum 
— which  include  12  cases  reported  by  Kraske,  47  (autopsies) 
by  Iverson,  and  8  by  Hemmeter — metastasis  occurred  in  31 
cases.  In  24  cases  observed  by  the  writer  secondary  deposits 
were  present  in  14  cases.  From  the  above  statistics  it  is  evi- 
dent that  metastasis  may  be  expected  in  approximately  50  per 
cent,  of  rectal  carcinomata.  Judging  by  the  few  reported  cases 
of  rectal  sarcomata,  it  would  appear  that  metastasis  is  more 
common  in  this  disease  than  in  rectal  carcinomata. 

Cancer  is  disseminated  principally  through  the  lymph- 
channels,  though  occasionally  the  disease  may  destroy  the  coats 
of  a.  blood-vessel  and  enter  the  circulation.  Because  of  the 
vascularity  of  sarcomata  and  their  close  relation  to  the  blood- 
vessels, metastasis  by  way  of  the  circulation  is  most  common, 
but  in  exceptional  cases  dissemination  may  take  place  through 
the  lymphatics.  Lymphosarcoma,  however,  is  always  intimately 
connected  with  the  lymphatic  glandular  system. 

Metastatic  deposits  from  malignant  disease  in  the  rectum 
may  involve  the  lymphatic  glands  (Plate  XXXV).  liver,  lungs, 
uterus,  ovaries,  kidneys,  peritoneum,  or  mesenteric  or  omental 


528 


DISEASES  OF  THE  RECTUM  AND  ANUS 


lymph-nodes  (Fig.  173).  The  Hver  is  most  frequently  involved, 
owing  to  the  fact  that  the  blood  from  the  venous  plexus  of  the 
rectum  is  carried  by  way  of  the  superior  hemorrhoidal  vein  to 
the  portal  vein  and  thence  to  the  liver. 

Mahgnant  disease  at  the  anus  involving  the  skin  or  the 
lower  rectum  causes  an  enlargement  of  the  inguinal  lymph- 
nodes,  and,  when  the  disease  is  located  higJi  up  in  the  bowel, 
the  retroperitoneal,  sacral,  and  lumbar  glands  are  afifected. 

Colloid  cancer  of  the  rectum  more  often  produces  metas- 


Fig.  173.— Carcinoma  (Secondary)  of  Mesenteric  Glands.  (Specimen  from 
Carnegie  Laboratory,  Photographed  by  the  Author  Through  the  Kindness 
of  Dr.  D.  Hunter  McAlpin,  Jr.) 

tasis  of  the  serosa,  lymph-nodes,  and  bones ;  medullary  cancer 
frequently  gives  rise  to  deposits  in  the  lymph-glands;  while 
the  scirrhous  form  of  the  disease  usually  affects  the  internal 
organs,  especially  the  liver. 

When  malignancy  exists  in  other  parts  of  the  body,  the 
rectum  is  very  rarely  the  site  of  secondary  growths. 

DIAGNOSIS 

The  diagnosis  of  malignancy  in  the  rectum  is  frequently 
confusing.     It  is  much  less  difficult,  however,  than  when  the 


MALIGNANT  TUMORS  529 

growth  is  located  in  other  parts  of  the  bowel,  owing  to  the  ease 
with  which  digital  and  proctoscopic  examinations  can  be  made. 
It  not  infrequently  happens  that  malignant  disease  exists  in  the 
rectum  for  a  considerable  time,  unsuspected  by  either  the  pa- 
tient or  physician.  For  this  reason  a  thorough  rectal  examination 
should  be  made  in  every  instance  in  which  an  elderly  person 
complains  of  chronic  diarrhea;  difficult  defecation;  discharge 
of  pus,  blood,  or  mucus ;  pain  or  sensations  of  weight  and  full- 
ness in  the  ano-rectal  region,  or  any  other  pronounced  symp- 
tom of  rectal  disease.  In  suspected  cancer  cases  it  is  always 
most  important  to  obtain  a  detailed  history  from  the  patient, 
especially  in  regard  to  the  length  of  time  the  disease  has 
existed. 

There  is  no  one  position  which  is  suitable  for  examination 
in  all  cases.  Consequently  the  patient  should  be  placed  in  a 
posture  which  offers  the  best  facilities  for  examination.  When 
the  growth  affects  the  skin  about  the  anus  or  is  situated  in  the 
lower  half-inch  (1.27  centimeters)  of  the  rectum,  it  can  be  in- 
spected by  separating  the  buttocks  and,  if  necessary,  requesting 
the  patient  to  strain  down.  If  the  disease  is  located  higher  up 
in  the  bowel,  its  nature  can  be  determined  by  digital  or  proc- 
toscopic examination,  or  both. 

Digital  Examination  is  by  far  the  more  reliable  method  of 
diagnosticating  these  growths  in  the  lower  three  or  four  inches 
(7.62  or  10.16  centimeters)  of  the  bowel.  The  educated  finger 
can  determine  not  only  the  location,  size,  number,  consistence, 
and  condition  of  the  tumors,  but  also  whether  the  neighboring 
structures  are  involved  and  to  what  extent.  When  the  tumor 
is  more  than  four  inches  (10.16  centimeters)  above  the  anus, 
its  location  and  nature  can  sometimes  be  ascertained  by  re- 
questing the  patient  to  stand  upright  and  bear  down  while  the 
finger  is  passed  up  into  the  bowel. 

Proctoscopic  and  Sigmoidoscopic  Examinations  are  not  so 
reliable  in  these  cases ;  but,  when  the  diagnosis  cannot  be  made 
by  the  finger,  they  are  of  great  service  in  locating  and  inspect- 
ing the  growth  in  any  part  of  the  rectum  or  sigmoid  flexure. 

Extreme  care  should  be  exercised  in  using  these  instru- 
ments. Force  should  never  be  employed,  because  of  the  danger 
of  rupturing  the  bowel,  should  it  be  ulcerated.  For  the  same 
reason  the  use  of  bougies  as  a  means  of  diagnosis  should  be  dis- 
countenanced. 


530  DISEASES  OF  THE  RECTUM  AND  ANUS 

Forcible  Introduction  of  the  Entire  Hand  into  the  bowel  for 
purposes  of  examination  is  to  be  deprecated.  Such  a  measure 
is  brutal,  extremely  dangerous,  unsatisfactory,  and  uncalled 
for  since  the  advent  of  the  proctoscope  and  colonoscope. 

If  the  history  of  the  disease  is  carefully  considered  squa- 
mous-celled  carcinoina  (epithelioma)  located  at  the  anus  may  be 
recognized  without  serious  difficulty  by  the  characteristic  ap- 
pearance of  the  growth.  When  seen  early,  it  presents  a  small, 
dry,  zvart-like  nodule,  which  is  totally  unlike  any  other  tumor  en- 
countered in  this  region.  When  not  observed  until  a  later 
period,  it  appears  as  a  progressive  idcer  of  variable  size  and 
shape,  with  elevated,  rounded  edges  having  a  violaceous  hue. 
When  the  ulceration  extends  upward  into  the  rectum,  it  may  be 
mistaken  for  a  syphilitic,  chancroidal,  or  tubercular  ulceration, 
but  differs  from  them  in  that  it  extends  more  rapidly  and  is  sur- 
rounded by  a  firm,  infiltrated  area  in  the  skin  and  mucous 
membrane. 

Cylindric-celled  carcinoina  situated  higher  up  in  the  rectum 
differs  materially  from  the  variety  just  mentioned.  In  the  be- 
ginning they  may  be  either  firm,  ovoid,  nodular  tumors  project- 
ing into  the  lumen  of  the  bowel,  or  flat  slightly-elevated,  indu- 
rated masses.  When  the  examination  is  made  at  a  later  stage  of 
the  disease,  the  tumors  are  of  such  size  as  to  produce  partial  or 
complete  obstruction,  and  are  firmly  bound  down  to  adjacent 
tissue.  They  are  irregular  in  shape,  and  their  surfaces  rough-" 
ened  by  deep,  puncJied-out,  crater-like  ulcerations.  This  con- 
dition is  characteristic  of  this  form  of  the  disease  and  imparts  to 
the  touch  a  sensation  not  likely  to  be  forgotten.  Furthermore, 
the  growth  may  be  felt  as  a  flat,  indurated,  band-like  constric- 
tion encircling  the  bowel,  in  many  cases  producing  complete 
occlusion  (carcinoma  retrahens).  This  latter  form  of  rectal 
cancer  is  not  infrequently  mistaken  for  syphilitic  stricture.  It 
should  be  remembered,  however,  that  a  rectal  ulceration  pro- 
longed for  several  years  antedates  S5^philitic  stenosis,  while 
annular  carcinoma  of  the  rectum  produces  an  equally  tight 
stricture  within  a  few  weeks  or  months,  and,  moreover,  is  fre- 
quently characterized  by  secondary  metastasis  (especially  in  the 
liver),  cachexia,  emaciation,  and  immobility  of  the  rectum,  due 
to  the  involvement  of  adjacent  structures. 

Cancerous  neoplasms  have  sometimes  been  confused  with 
coccygeal,  pelvic,  vesical,  uterine,  and  vaginal  tumors;   vesical 


6s 

as 


2^ 


H 

a 


MALIGNANT  TUMORS  531 

calculi ;  chronic  enlargement  of  the  prostate ;  inflammatory 
deposits  due  to  blind  fistulous  sinuses,  and  fecal  impaction. 
Again,  simple  adenomata,  lipomata,  fibromata,  and  ulcerated 
or  indurated  hemorrhoids  have  been  diagnosticated  as  cancer. 
Of  these  latter  affections,  adenomata  or  polyps  are  the  most 
frequently  confused  with  carcinoma,  because  they  often  attain 
considerable  size,  may  be  soft  or  hard,  become  ulcerated  and 
bleed  more  or  less,  and  when  multiple  are  usually  accompanied 
by  a  profuse  discharge  of  pus  and  blood. 

Clinically,  polyps  are  dilTerentiated  from  cancer  by  the  fact 
that  they  occur  in  young  subjects,  are  pedunculated  and  fre- 
quently protrude,  have  a  non-indurated  base,  and  do  not  in- 
volve the  perirectal  structures  or  attack  neighboring  organs  or 
produce  cachexia  or  metastasis.  It  is  well  to  remember,  how- 
ever, that  adenomata  which  have  remained  innocent  for  3^ears 
may  become  transformed  into  malignant  adenomata  as  a  result 
of  irritation  or  other  cause. 

Another  point  in  the  diagnosis  of  rectal  carcinoma  is  that 
the  inguinal  glands  are  affected  when  the  growth  is  at  the  anus 
(squamous-celled  cancer),  and  the  lumbar  and  sacral  glands, 
when  the  disease  is  higher  up  in  the  rectum  (cylindric-celled 
carcinoma). 

The  Diagnosis  of  Sarcoma  is  frequently  a  matter  of  much 
anxiety.  In  some  cases  it  is  extremely  difficult  to  differentiate 
between  this  growth  and  various  other  diseases  encountered  in 
the  ano-rectal  region.  It  has  most  frequently  been  confused 
with  syphilis,  tuberculosis,  inflammatory  deposits,  lipomata, 
fibromata,  and  carcinomata. 

The  syphilitic  manifestations  which  most  resemble  sarcoma 
are  stricture  and  gumma.  The  former,  however,  is  preceded 
by  prolonged  ulceration,  which  produces  tight,  cicatricial  oc- 
clusion totally  unlike  the  circular,  indurated,  rapidly-developing 
stenosis  of  sarcoma.  Gummata,  while  flat  and  somewhat  ovoid 
in  shape,  do  not  attain  the  extensive  size  or  distinct  tumor- 
formation  which  marks  sarcoma ;  nor  do  they  involve  the  ad- 
jacent structures  or  produce  metastasis.  By  obtaining  a  care- 
ful history  of  the  case  the  diagnosis  of  syphilis  is  made  most 
clear.  Too  much  reliance  should  not  be  placed  on  the  iodides 
in  doubtful  cases. 

Tubercular  glands  have  been  confused  with  sarcoma,  espe- 
cially lymphosarcoma.     By  a  close  clinic  study,  however,  they 


532  DISEASES  OF  THE  RECTUM  AND  ANUS 

can  be  differentiated  from  the  latter  because  they  enlarge  less 
rapidly,  are  more  sensitive  and  irregular  in  shape,  and  the 
patient  usually  gives  a  family  history  of  tuberculosis. 

Inflammatory  deposits  following  chronic  inflammation  in  the 
rectum,  female  generative  organs,  and  prostate  have  in  rare 
instances  been  taken  for  sarcomatous  tumors.  The  slow  forma- 
tion of  such  deposits  and  their  lack  of  sharply-defined  outlines 
eliminate  them  from  the  diagnosis  in  most  cases. 

Lipoma  and  fibroma  of  the  rectum  are  unlike  sarcoma,  in 
that  they  grow  very  slowly,  manifest  no  tendency  to  recur,  do 
not  produce  cachexia  or  metastasis,  cause  less  pain,  are  inclined 
to  become  pedunculated,  and  rarely,  if  ever,  cause  death. 

Carcinoma  is  the  most  liable  of  all  to  be  confused  with  sar- 
coma. It  differs  from  the  latter  in  that  it  but  rarely  occurs 
in  childhood,  is  inclined  to  tdcerate  early  and  deeply,  more 
often  secondarily  involves  the  lymphatic  glands,  and  usually 
produces  metastasis  earlier  in  its  course ;  moreover,  the  tumor 
of  carcinoma  is  less  movable  and  more  difficult  to  outline  than 
is  that  of  sarcoma. 

The  Examination  of  the  Feces  is  important  in  doubtful  cases 
of  neoplasms  of  the  intestine.  Not  infrequently  some  idea  of 
the  nature  of  the  growth  can  be  had  from  macroscopic  and 
microscopic  examination  of  the  excreta.  Their  shape,  con- 
sistence, and  contents  should  be  accurately  determined. 

Some  authorities  maintain  that  reliable  information  is  to 
be  gained  from  examination  of  the  blood  and  urine  in  sus- 
pected malignancy,  but  experience  has  shown  that  too  much 
importance  should  not  be  given  these  tests,  which  have  not 
proved  reliable  in  all  cases. 

Examination  of  the  blood  reveals  the  fact  that  there  is  a 
decrease  in  the  specific  gravity,  in  the  number  of  red  corpus- 
cles, and  in  the  amount  of  hemoglobin.  Furthermore  there  is 
a  moderate  leucocytosis  in  cancer,  and  this  is  more  pronounced 
in  sarcoma. 

Examination  of  the  urine  in  cancer  shows  the  presence  of 
a  large  amount  of  indican  and  a  decrease  in  the  amount  of 
nitrogen  excreted. 

In  all  doubtfid  cases  of  tumor-formation  in  the  rectum  zvhere 
malignancy  is  suspected,  a  portion  of  the  neoplastic  tissue  should  be 
removed  and  carefidly  examined  microscopically,  in  order  to  deter- 
mine the  nature  of  the  grozvth. 


MALIGNANT  TUMORS  533 

PROGNOSIS 

As  in  other  parts  of  the  body,  the  prognosis  of  carcinoma 
and  sarcoma  of  the  rectum  is  always  exceedingly  grave.  Only 
in  exceptional  cases  can  the  patient  be  offered  any  hope 
of  permanent  relief.  Much,  however,  can  be  accomplished 
through  palliative  and  surgical  procedures  toward  prolonging 
life  and  relieving  the  pain,  obstruction,  and  other  prominent 
symptoms,  thus  adding  greatly  to  the  comfort  of  the  sufferer. 

For  Literature  of  Malignant  Tumors  (Cancer)  of  the  Rectum 
and  Anus  see  pages  577  to  581. 


CHAPTER  XXXIII 

TREATMENT  OF    MALIGNANT  TUMORS 

Malignant  neoplasms  of  the  ano-rectal  region  require 
radical  treatment.  The  growth,  whether  carcinoma  or  sar- 
coma, should  be  completely  extirpated,  if  possible,  at  the  earliest 
opportunity.  Radical  procedures  are  contra-indicated,  how- 
ever, when  adjacent  organs  and  structures  are  extensively  in- 
volved, when  the  patient's  vitality  is  low,  or  when  it  is  apparent 
that  no  additional  comfort  will  be  derived  from  the  operation. 
While  palliative  measures  accomplish  but  little  toward  a  per- 
manent cure,  their  application  in  inoperable  cases  prolongs  life, 
materially  diminishes  the  suffering  of  the  patient,  and  in  some 
instances  retards  or  arrests  the  progress  of  the  disease. 

The  treatment  of  malignant  disease  in  the  ano-rectal  re- 
gion will  be  discussed  under  three  headings : — 

1.   Palliative.     2.   Surgical  palliative.     3.   Radical. 

PALLIATIVE  TREATMENT 

The  palHative  treatment  of  malignancy  in  this  locality  con- 
sists in : — 

1.  Improving  the  general  condition  of  the  patient. 

2.  Regulating  the  diet. 

3.  Relieving  the  symptoms  of  occlusion. 

4.  Cleanliness  and  treatment  of  ulceration. 

5.  Relieving  the  pain. 

6.  Treatment  of  complications. 

7.  Treatment  by  electricity. 

8.  Treatment  by  the  Roentgen  ray. 

9.  Treatment  by  internal  medication  and  the  subcutane- 
ous and  parenchymatous  injection  of  sera  (toxins). 

10.  Treatment  by  chemic  caustics  and  the  thermocautery. 
The  general  condition  of  the  patient  should  be  improved  as 

far  as  possible  by  the  administration  of  tonics  and  nourishing 
foods,  improvement  of  hygienic  surroundings,  moderate  exer- 
cise, giving  him  the  benefit  of  the  fresh  air  and  sunshine  and 
encouraging  him  if  inclined  to  become  despondent. 
(534) 


PLMTE  XXXJI 


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Metastasis  in  Inguinal  Lymph- no de,  Sscondary  to  Rectal  Carcinoma, 


TKEATMENT  OF  MALIGNANT  TUMORS  535 

The  diet  is  an  important  feature.  The  patient  should  be 
allowed  only  such  foods  as  are  easily  digested  and  which  leave 
little  residue  and  tend  to  increase  peristalsis.  Milk,  concen- 
trated soups,  soft-boiled  eggs,  beef-juice,  Brush's  koumiss, 
matzoon,  malt-extracts,  and  like  foods  are  especially  suited  to 
these  cases.  Meat  and  fish  should  be  partaken  of  sparingly  and 
only  in  the  most  digestible  forms.  Coarse  vegetables  and  fruits 
should  not  be  eaten  unless  properly  cooked  and  strained. 

The  most  important  feature,  by  far,  in  the  inoperable 
treatment  of  malignant  growths  in  the  rectum  is  the  relief  and 
prevention  of  obstruction.  In  fact,  a  great  many  of  these  patients 
seem  to  live  longer  without  an  operation  if  the  feces  are  pre- 
vented from  collecting  above  the  growth  and  the  rectum  is 
kept  free  from  foul  discharges  by  frequent  irrigation.  In  addi- 
tion to  restriction  of  the  diet,  accumulation  of  the  feces  should 
be  prevented  by  regulating  the  stools  and  keeping  the  lumen 
of  the  bowel  sufficiently  free  to  permit  the  passage  of  the  liquid 
and  semisolid  feces.  The  author  has  frequently  obtained  a  suit- 
able consistency  of  the  stools  from  the  administration  of  olive- 
oil  in  tablespoonful  doses,  three  times  a  day;  the  oil  not  only 
softens  and  lubricates  the  feces,  but  reduces  tenesmus  by  its 
soothing  effect  upon  the  inflamed  and  ulcerated  mucosa.  Cas- 
tor-oil is  also  of  service,  but  is  not  so  palatable  or  reliable  as 
sweet  oil. 

Laxative  mineral  waters,  such  as  Carabaha  water ;  and 
drugs,  such  as  Seidlitz  powders,  Glauber's  and  Epsom  salts, 
licorice-powder,  cascara  sagrada,  and  like  remedies  which  in- 
crease peristaltic  action,  stimulate  glandular  secretion,  and 
soften  or  liquefy  the  dejecta,  should  be  given  as  frequently  and 
in  as  large  doses  as  may  be  necessary. 

When  fecal  impaction  exists  above  the  growth,  internal 
medication  is  not  sufficient.  It  then  becomes  necessary  to  re- 
move the  fecal  mass  by  massage,  or  by  breaking  it  up  with  the 
finger  or  instrument,  in  conjunction  with  frequent  and  copious 
•enemata  of  soap-suds  or  warm  water  to  which  may  be  added  a 
few  ounces  of  oil,  glycerin,  or  both.  The  injections  should  be 
administered  through  a  colon-tube,  or,  if  the  stenosis  is  tight, 
through  a  small,  flexible,  rubber  catheter,  passed  well  above  the 
growth.  The  feces  are  frequently  hard,  nodular,  and  covered 
with  mucus.  In  order  to  soften  them,  the  enemata  must  be 
given  at  short  intervals,  and  should  be  retained  as  long  as  pos- 


536  DISEASES  OF  THE  RECTUM  AND  ANUS 

sible.  In  these  cases  of  coprostasis,  drastic  purgatives  are 
always  contra-indicated. 

When  the  occlusion  is  complete,  it  is  necessary  to  dilate 
the  lumen  of  the  bowel  sufficiently  to  permit  the  passage  of 
the  colon-tube  or  catheter.  This  should  always  be  accom- 
plished with  the  finger  if  possible,  but  bougies  should  be  em- 
ployed if  the  stricture  is  beyond  the  reach  of  the  finger.  Bou- 
gies should  always  be  used  with  extreme  caution,  to  avoid  the 
danger  of  perforating  or  rupturing  the  ulcerated  bowel.  Pre- 
vious to  their  introduction,  the  bowel  should  be  carefully 
examined  through  the  proctoscope. 

The  ulceration  of  mahgnant  disease  of  the  rectum  is  usu- 
ally deep  and  involves  a  large  area  of  the  bowel.  The  discharge 
from  these  ulcers  is  abundant,  and  becomes  very  offensive  and 
irritating  when  retained.  Moreover,  the  ulcers  serve  as  a  place 
of  lodgment  for  fecal  matter,  which  adds  to  the  discomfort  of 
the  patient.  Cleanliness,  therefore,  is  essential.  The  rectum 
should  be  frequently  irrigated  with  warm  sterile  water  or  anti- 
septic or  astringent  solutions.  Solutions  containing  carbolic 
acid;  bichloride  of  mercury;  nitrate,  citrate,  or  lactate  of  silver; 
permanganate  of  potassium ;  boric  acid ;  formalin ;  fluid  ex- 
tract of  krameria,  or  hydrastis  are  all  reliable  agents  for  their 
cleansing  and  stimulating  qualities.  Weak  solutions  are  always 
preferable.  If  the  solutions  are  strong,  they  are  likely  to  cause 
irritation,  tenesmus,  or  colicky  pains.  In  the  author's  opinion, 
the  rise  of  temperature,  so  often  attributed  to  the  neoplasm,  in 
these  cases  is  due  largely  to  the  accumulation  of  the  foul  dis- 
charge and  fecal  matter ;  when  the  rectum  is  properly  cleansed, 
this  symptom  subsides. 

Cleanliness  is  equally  necessary  when  the  growth  and 
ulceration  are  located  at  the  anus  and  involve  the  external 
parts. 

The  problem  of  relieving  pain  in  cases  of  malignancy  in 
this  region  is  one  of  the  most  difficult  with  which  the  physician 
has  to  contend.  Opium  is  necessary  in  nearly  every  case,  but 
the  practice  of  freely  administering  this  drug  as  soon  as  a  diag- 
nosis of  cancer  is  made  cannot  be  too  severely  condemned.  In 
the  earlier  stages  of  the  disease  the  suffering  is  not  great,  and 
in  most  instances  can  be  prevented  or  alleviated  by  improving 
the  hygienic  condition  of  the  bowel.  The  use  of  opium  is  sel- 
dom called  for  at  this  time.     If  prescribed  promiscuously,  the 


TREATMENT  OF  MALIGNANT  TUMORS  537 

patient  soon  becomes  an  habitue  of  the  drug,  and  it  fails  to  give 
relief  at  a  later  period  when  it  is  most  needed.  In  the  later 
stages,  however,  the  pain  is  continuous  and  agonizing,  owing 
to  the  enormous  growth  filling  up  the  pelvis  and  involving, 
by  pressure  or  ulceration,  the  nerves  and  adjacent  structures. 
It  is  now  imperative  and  justifiable  to  give  opium  in  doses  suffi- 
cient to  relieve  the  horrible  suffering  and  procure  sleep. 

The  author  prefers  to  administer  morphine  hypodermic- 
ally  in  these  cases.  The  drug  may,  however,  be  given  by 
mouth,  applied  topically  in  the  form  of  suppositories  or  oint- 
ment; or  the  tincture  of  opium  combined  with  starch-water 
may  be  injected  into  the  rectum  as  often  as  is  necessary. 

Complications — such  as  abscesses,  fistula,  hemorrhage,  pru- 
ritus, vegetations,  hemorrhoids,  fissures,  etc. — should  be 
treated  by  the  methods  outlined  elsewhere  for  the  relief  of 
these  conditions. 

Some  authorities  on  electrotherapeutics  speak  highly  of 
electricity  applied  in  various  ways  in  the  treatment  of  malignant 
neoplasms.  There  is  little  reason  to  believe,  however,  that  any 
permanent  good  results  are  to  be  expected  from  this  agent. 
The  writer  has  seen  several  cases  in  which  the  progress  of  the 
growth  was  apparently  retarded  by  electric  treatment,  but  he 
has  yet  to  see  one  cured  by  it. 

The  Roentgen  rays  have  been  used  with  a  fair  degree  of 
success  by  Dr.  Francis  H.  Williams  in  treating  superficial  can- 
cerous growths.  He  believes  that  the  x-rays  will  prove  useful 
in  internal  cancer;  but  this  has  not  as  yet  been  determined. 
He  exposes  the  affected  part  to  the  rays  for  five  minutes  each 
day.  It  is  thought  that  the  good  effects  derived  from  this 
treatment  are  due  to  the  inflammation  excited  by  the  electro- 
lytic discharges  generated  in  the  integument  by  the  high-poten- 
tial current.  The  only  form  of  malignant  neoplasm  of  the  ano- 
rectal region  in  which  it  might,  in  the  author's  opinion,  be 
.  justifiable  to  employ  the  Roentgen  rays  is  the  squamous-celled 
epithelioma  involving  the  skin  at  the  anal  margin.  Owing  to 
the  extensive  burns  which  have  at  times  been  caused  by  use 
of  the  x-rays  in  other  parts  of  the  body,  the  author  has  not 
employed  this  treatment  extensively  in  rectal  cancer. 

The  internal  administration  of  different  remedies  and  the 
subcutaneous  and  parenchymatous  injection  of  various  agents  and 
sera    (toxins)   have  been  used  in  the  treatment    of  malignant 


538  DISEASES  OF  THE  RECTUM  AND  ANUS 

tumors,  but  the  writer  has  never  observed,  nor  does  he  knowr 
of,  a  case  of  mahgnancy  of  the  rectum  wherein  a  cure  was 
effected  by  either  of  these  methods.  According  to  the  success- 
ful resuhs  reported  from  the  injection  of  the  mixed  toxins  of 
the  streptococcus  erysipelatis  and  the  bacillus  prodigiosus  into  sar- 
coma in  other  parts  of  the  body,  as  advised  by  Coley,  it  would 
seem  that,  under  favorable  conditions,  sarcomata  in  the  rectum 
might  yield  to  this  form  of  treatment.  However  this  may  be, 
the  writer  has  not  observed  any  such  fortunate  results. 

Chemic  caustics  and  the  thermocautery  are  contra-indicated 
in  the  treatment  of  malignant  neoplasms  in  the  ano-rectal  re- 
gion, except  when  the  growth  is  located  at  the  anal  margin 
or  is  soft  and  protrudes  through  the  anus.  In  such  cases  the 
growth  may  be  partially  or  completely  destroyed.  Acids  have 
been  used  as  cauterizing  agents,  but  chlorides  of  zinc  and  ar- 
senic have  proved  the  most  reliable,  and  have  therefore  been 
extensively  used  in  the  form  of  pastes.  A  simple  method  of 
preparing  the  zinc  paste  is  to  mix  equal  parts  of  chloride  of 
zinc  and  flour  with  sufffcient  water  to  make  a  paste.  Bryant, 
of  London,  prepares  the  zinc  paste  after  the  following  for- 
mula:— 

IJ  Chloride  of  zinc 2  parts. 

Muriate  of  antimony 2  parts. 

Flour  3  parts. 

Water,  sufficient  to  make  soft  paste. 
M.     Sig. :    Apply  on  cotton  or  gauze. 

These  caustic  pastes  should  be  applied  to  the  growth,  on 
cotton  or  gauze,  and  retained  in  place  by  adhesive  strips  or  a 
properly-adjusted  bandage  for  several  hours,  until  a  slough  is 
produced.  This  method  of  treating  cancer  about  the  rectum 
is  unsatisfactory  because  of  the  difficulty  of  limiting  the  action 
of  the  caustic  to  the  involved  area,  the  unfavorable  results 
obtained,  and  the  great  pain  which  follows  the  applications. 

In  cases  where  it  is  desirable  to  destroy  the  growth  by 
cauterization,  the  author  has  found  the  Paquelin  cautery  more 
expeditious  and  accurate,  accompanied  by  less  pain,  and  more 
reliable  than  chemic  caustics. 

It  should  be  borne  in  mind  that  the  treatment  of  malignant 
neoplasms  in  this  region  by  cauterisation  should  not  be  attempted 
except  in  cases  in  ivJiich  tJie  patient  refuses  to  submit  to  more  radical 


TREATMENT  OF  MALIGNANT  TUMORS  539 

procedures  or  there  are  strong  contra-indications  to  complete  extirpa- 
tion of  the  growth. 

SURGICAL   PALLIATIVE  TREATMENT 

The  surgical  palliative  procedures  for  the  relief  of  malig- 
nant disease  in  the  ano-rectal  region  are,  in  the  order  of  their 
importance : — 

1.  Colostomy.  3.  Curettage. 

2.  Proctotomy.  4.   Forcible  divulsion. 

None  of  the  above-named  operations,  with  the  exception 
of  colostomy,  should  be  performed  in  any  case  where  the  disease 
is  located  more  than  three  and  one-half  inches  (8.9  centime- 
ters) above  the  anus,  because  of  the  danger  of  peritonitis  should 
the  bowel  be  cut  through,  perforated  by  the  curette,  or  torn 
by  the  stretching. 

Colostomy.  — ■  Depending  upon  the  object  to  be  accom- 
plished, colostomy  is  temporary  or  permanent.  Temporary  or 
preliminary  colostomy  is  performed  with  the  object  of  prevent- 
ing the  fecal  current  from  passing  through  the  lower  bowel, 
when  it  is  intended,  at  a  subsequent  time,  to  amputate  or  resect 
the  rectum.  By  this  procedure  the  operation  of  excision  is 
facilitated  and  the  danger  of  infection  materially  lessened. 
When  the  temporary  artificial  anus  has  served  its  purpose  it 
may  be  closed  by  the  methods  outlined  elsewhere. 

Permanent  Colostomy  should  be  resorted  to  in  inoperable 
cases  of  malignant  growth  of  the  lower  bowel,  in  order  to  re- 
lieve or  prevent  pain,  diarrhea,  fecal  impaction,  and  other  dis- 
tressing symptoms  of  obstruction.  This  operation,  moreover, 
obviates  the  discomfort  caused  the  patient  by  the  feces  passing 
or  becoming  lodged  in  the  ulcers,  and  permits  the  rectum  to 
be  thoroughly  cleansed  and  treated  by  irrigations  and  applica- 
tions, from  both  above  and  below.  By  the  operation  of  colos- 
tomy hfe  is  frequently  prolonged  for  a  considerable  time,  and 
in  many  instances  these  patients,  relieved  of  their  sufferings, 
gain  rapidly  in  weight  and  become  hopeful  of  recovery.  It  is 
not  well  to  discourage  this  behef,  but  the  patient's  friends 
should  be  warned  that  permanent  relief  never  follows  colostomy 
alone,  and  that  death  must  eventually  ensue  from  the  extension 
of  the  disease  or  from  secondary  involvement  of  the  internal 
organs.     The  relief  from  pain  following  colostomy  is  not  so 


540  DISEASES  OF  THE  RECTUM  AND  ANUS 

great  when  the  bony  structures  or  neighboring  organs  are  in- 
volved as  when  the  disease  is  confined  to  the  bowel. 

The  indications  for  colostomy,  temporary  and  permanent, 
and  the  methods  of  performing  this  operation  are  fully  dis- 
cussed in  the  next  chapter,  to  which  the  reader  is  referred  for 
further  information  on  the  subject. 

Proctotomy.  —  When  a  more  radical  operation,  which  is 
preferable,  seems  inadvisable  or  is  decHned,  and  there  are 
urgent  symptoms  of  obstruction,  proctotomy  may  be  per- 
formed, provided  the  uppermost  limit  of  the  growth  is  not  more 
than  three  and  one-half  inches  (8.9  centimeters)  above  the  anus. 
Proctotomy  may  be  (a)  internal  or  (b)  complete. 

In  the  internal  operation  a  probe-pointed  bistoury,  guided 
by  the  finger,  is  carried  above  the  growth,  which  is  then  in- 
cised sufficiently  to  relieve  the  obstruction.  External,  or  com- 
plete, proctotomy  is  done  in  the  same  manner,  but  the  knife 
is  brought  downward  and  out,  completely  dividing  the  sphinc- 
ter-muscle, making  a  deep,  triangular  wound. 

In  either  operation  the  cut  should  be  made  in  the  posterior 
median  line.  In  some  cases,  however,  it  is  necessary  to  divide 
the  growth  in  more  than  one  place,  and  the  cuts  should  then  be 
made  in  the  posterior  lateral  walls.  The  bowel  should  never 
be  incised  anteriorly,  because  of  the  danger  of  injuring  the 
bladder,  urethra,  prostate,  or  vagina. 

Because  of  the  profuse  bleeding,  the  wound  should  be 
packed  tightly  for  the  first  twenty-four  hours  to  prevent  dan- 
gerous post-operative  hemorrhage.  Unless  bougies  are  fre- 
quently passed  during  the  after-treatment,  the  obstruction  soon 
recurs,  and  it  is  necessary  to  repeat  the  operation. 

External,  or  complete,  proctotomy  is  preferable  to  the 
internal  operation,  because  the  wound  can  be  easily  drained 
and  the  danger  of  infection  thus  diminished. 

Curettage.  —  Curettage  for  the  relief  of  obstruction  or 
hemorrhage  caused  by  maHgnant  disease  of  the  upper  rectum  is 
a  very  dangerous  procedure.  It  is  applicable  only  in  medullary 
(soft)  cancers  which  fill  up  the  lumen  of  the  bowel  with  their 
cauliflower-like  protuberances,  or  which  are  friable  and  bleed 
freely  during  stool.  Under  general  anesthesia  all  the  tumor- 
masses  should  be  carefully  and  quickly  detached  with  the 
curette  or  the  fingers,  and  the  rectum  then  packed  with  gauze 
to  prevent  hemorrhage.    The  writer  has  reluctantly  resorted  to 


TREATMENT  OF  MALIGNANT  TUMORS  541 

curettage  in  a  few  cases,  and  succeeded  in  relieving  the  obstruc- 
tion or  hemorrhage  for  a  short  time ;  in  each  instance,  however, 
the  growth  returned  after  a  brief  interval,  and  a  repetition  of 
the  procedure  was  necessary. 

Forcible  Divulsion.  —  General  anesthesia  is  necessary  for 
this  operation,  and  the  divulsion  should  never  require  more 
than  five  minutes.  The  dilatation  can  be  accomplished  with 
the  fingers  or  mechanic  dilators.  The  author  prefers  to  divulse 
with  the  fingers.  He  proceeds  by  first  introducing  the  index 
finger  through  the  occlusion  and  then  inserting  one  finger  after 
another  until  the  lumen  of  the  bowel  is  sufficiently  increased, 
being  careful  not  to  use  enough  force  to  rupture  the  intestine. 

After  proctotomy,  curettage,  or  forcible  divulsion,  when 
fecal  impaction  exists,  the  mass  should  be  broken  up  and  dis- 
lodged, if  possible,  and  the  bowel  thoroughly  irrigated  before 
the  dressings  are  applied. 

In  concluding  the  surgical  palliative  treatment  of  cancer 
of  the  rectum  the  writer  wishes  to  emphasize  the  fact  that  these 
procedures  are  not  curative,  but  solely  palliative  measures. 


RADICAL   TREATMENT 

The  radical  treatment  of  mahgnant  disease  has  for  its 
object  the  extirpation  of  every  vestige  of  the  growth  and  in- 
volved structures.  This  may  necessitate  the  removal  of  but 
a  small  part  of  the  bowel  or  the  excision  of  the  entire  rectum, 
the  operation  being  known  as  proctectomy. 

Extirpation  of  the  malignant  neoplasm  is  the  only  method 
of  treatment  which  offers  the  patient  any  hope  of  permanent 
relief.  It  should  therefore  be  undertaken  in  every  case  in  which 
it  is  practicable.  Unless  the  removal  of  the  disease  can  be  made 
complete,  the  radical  operation  is  contra-indicated  and  the  case 
hopeless;  but  the  patient's  suffering  should  be  relieved  and 
his  life  prolonged,  so  far  as  possible,  by  the  palliative  and  sur- 
gical measures  already  discussed. 

Some  authors  of  considerable  experience  frown  upon  the 
radical  treatment  of  mahgnant  neoplasms,  while  others  go  to 
the  opposite  extreme  and  advocate  the  removal  of  the  disease, 
even  though  it  extensively  involve  the  ureters,  bladder,  urethra, 
prostate,  vagina,  uterus,  or  other  adjacent  structures  and  the 
near-by  lymphatic  nodes. 


542  DISEASES  OF  THE  EECTUM  AND  ANUS 

Unless  the  patient  insists  upon  the  removal  of  the  growth, 
irrespective  of  its  extent  and  the  outcome  of  the  operation, 
it  has  been  the  custom  of  the  author  to  resort  to  amputation 
or  resection  of  the  diseased  rectum  only  when  the  latter  is  not 
bound  down  to  adjacent  structures  and  the  growth  can  be 
extirpated  without  extensive  injury  to  adjacent  organs.  The 
author  would  not  imply,  however,  that  it  is  always  possible  to 
avoid  injury  to  neighboring  organs;  on  the  contrary,  in  ap- 
parently favorable  cases  the  operation  may  show  that  adjacent 
organs  are  more  or  less  involved,  and  that,  if  the  extirpation 
of  the  growth  is  proceeded  with,  it  is  necessary  to  remove  por- 
tions of  these  structures. 

When  metastasis  of  the  internal  organs  and  distant  lymph- 
nodes,  pronounced  cachexia,  and  involvement  of  the  adjacent 
structures  exist,  or  when  the  patient  is  very  old,  or  has  serious 
heart,  lung,  kidney,  or  liver  disease,  it  is  inadvisable  to  attempt 
resection  or  amputation  of  the  rectum  for  the  relief  of  malig- 
nant disease. 

The  Preparation  of  the  Patient. — The  method  of  preparing 
the  patient  for  the  removal  of  all  or  a  part  of  the  rectum  does 
not  differ  materially  from  that  for  major  operations  in  other 
parts  of  the  body  in  which  the  operator  hopes  to  obtain  pri- 
mary union. 

The  intestine  should  be  emptied  of  fecal  matter  and 
cleansed  as  thoroughly  as  possible.  When  obstruction  is  only 
partial  and  there  is  a  fair  chance  of  removing  fecal  accumula- 
tion by  means  of  cathartics  and  irrigations  through  the  colon- 
tube  passed  above  the  growth,  such  measures  should  be  em- 
ployed even  though  several  days  are  required  to  accomplish 
the  desired  result.  On  the  other  hand,  if  obstruction  is  com- 
plete, or  nearly  so,  the  rectum  below  the  growth  should  be 
cleansed.  Strong  cathartics  or  purgatives,  however,  must  not 
be  employed  in  these  cases,  because  the  feces  cannot  pass  the 
constriction,  and  the  increased  peristalsis  and  straining  excited 
by  such  agents  add  much  to  the  patient's  discomfort  and  may 
cause  rupture  of  the  bowel.  Hardened  fecal  masses  are  less 
difficult  to  deal  with  during  the  operation  than  feces  made 
liquid  by  cathartics.  Hochenegg  has  abandoned  all  attempts 
to  empty  the  bowel  of  fecal  impactions  prior  to  excision  or  am- 
putation of  the  rectum. 

The  diet  for  a  few  days  preceding  the  operation  should  be 


TREATMENT  OF  MALIGNANT  TUMORS  543 

light  and  consist  principally  of  liquid  food.  The  skin  about 
the  anus  and  the  sacro-coccygeal  region  should  be  shaved, 
scrubbed,  and  rendered  aseptic,  and  the  mucosa  made  equally 
clean.  When  the  excision  is  to  be  preceded  by  preliminary 
colostomy,  or  the  growth  is  high,  necessitating  its  removal 
through  the  abdomen,  the  abdominal  integument  is  prepared 
in  the  same  aseptic  manner.  The  lower  end  of  the  bowel  should 
be  ligated  or  closed  by  suture  in  order  to  protect  the  wound 
against  infection  from  this  source.  Ouenu  holds  that  it  is  im- 
possible to  render  the  rectum  safe  by  antiseptic  irrigations.  He 
succeeded  in  making  cultures  of  the  colon  bacillus  and  strepto- 
coccus in  every  case  after  the  rectum  had  been  washed  out  with 
potassium-permanganate  solutions. 

The  Surgical  Treatment  of  Squamous-Celled  (True)  Epithelioma 
involving  the  skin  and  anal  margin  (anal  cancer)  consists  in 
excising  the  growth  and  closing  the  wound  with  catgut,  pro- 
vided there  is  not  too  much  tension.  Otherwise  the  wound 
should  be  permitted  to  heal  by  granulation. 

PROCTECTOMY    (EXCISION) 

The  principal  operations  devised  for  the  permanent  relief 
of  mahgnant  disease  of  the  rectum  are : — 

1.  Inferior  proctectomy.  4.   Laparo-proctectomy. 

2.  Superior  proctectomy.  5.   Proctectomy    by    invag- 

3.  Vaginal  proctectomy.  ination. 

Before  giving  the  histor)'-  of  these  operations,  the  author 
wishes  to  explain  the  terms  inferior  proctectomy  and  superior 
proctectomy.  The  former  (Lisfranc's  operation)  has  been  uni- 
versally described  as  perineal  excision  of  the  rectum ;  but  why 
"perineal"  is  applied  to  the  procedure  is  not  clear  to  the  author, 
since  the  bowel  is  not  excised  through  the  perineum,  and  the 
operation  has  but  little  to  do  with  that  region.  In  Kraske's 
operation  of  sacral  excision  of  the  rectum  the  bowxl  is  ap- 
proached from  above,  and  in  Lisfranc's,  or  the  so-called  "peri- 
neal," operation  it  is  attacked  from  below;  for  this  reason,  the 
author  prefers  to  employ  the  terms  superior  proctectomy  and  in- 
ferior proctectomy  to  designate  the  Kraske  and  Lisfranc  opera- 
tions, respectively,  which  are,  in  the  author's  opinion,  more 
descriptive  of  the  procedures. 

The  history  of  the  operation  of  proctectomy,  or  of  resection 


544  DISEASES  OF  THE  RECTUM  AND  ANUS 

and  amputation  of  the  rectum,  is  somewhat  obscure.  It  ap- 
pears, from  the  records,  that  the  operation  was  performed  by 
Faget  in  1739  for  the  reHef  of  a  dissecting  abscess  surrounding 
the  lower  part  of  the  rectum.  In  1824  Morgagni  attempted 
excision  of  the  rectum,  but  did  not  complete  the  operation. 
In  1826,  Lisfranc,  a  French  surgeon,  successfully  excised  the 
rectum  for  the  relief  of  a  malignant  growth,  and  the  operation 
was  popularized  through  the  contributions  to  the  literature  on 
the  subject  made  by  Lisfranc  and  his  student,  Penault,  between 
the  years  1829  and  1834. 

Lisfranc's  Method  of  Kemoving  (Excision)  a  Cancerous  Rectum 
consisted  in  making  two  semilunar  incisions,  embracing  the 
anus,  about  an  inch  (2.54  centimeters)  from  its  margin  and  unit- 
ing anteriorly  and  posteriorly ;  when  necessary  to  gain  room,  a 
longitudinal,  posterior,  median  incision  was  made  through  the 
rectal  wall  and  brought  downward  and  backward  to  connect 
behind  the  incision  surrounding  the  anus.  Lisfranc  limited  the 
operation  to  cases  where  the  growth  could  be  reached  by  the 
examining  finger  and  the  perirectal  tissues  were  healthy,  per- 
mitting the  rectum  to  be  freed  and  drawn  downward. 

During  the  succeeding  years  the  operation  was  slightly 
modified  and  improved  by  Velpeau,  Vidal  de  Cassis,  Chassaig- 
nac,  Demonvilliers,  and  Recamier.  In  1873  Verneuil  suggested 
that  resection  of  the  coccyx  would  give  additional  room  and 
thus  facilitate  the  operation,  and  shortly  thereafter  Kocher, 
Byrd,  Lange,  Bardenheuer,  and  Arnd  successfully  performed 
the  operation  thus  modified,  and  reported  that  it  had  many 
advantages.  In  1874,  Kocher,  of  Berne,  published  his  method 
of  excision,  which  consisted  of  a  long  posterior  cut,  excision 
of  the  coccyx,  and,  if  required,  free  incision  of  the  peritoneum; 
by  this  procedure  he  gained  considerable  room,  and  was  en- 
abled to  free  the  rectum  entirely  around  from  above,  and  draw 
it  downward.  In  cases  which,  prior  to  this  time,  were  consid- 
ered inoperable,  he  could  thus  extirpate  growths  located  above 
the  peritoneal  attachments  of  the  rectum. 

In  order  to  gain  still  more  room  and  permit  the  operator 
to  reach  and  excise  or  resect  growths  situated  in  the  upper 
part  of  the  rectum  and  lower  sigmoid,  Bardenheuer.  in  1880, 
proposed  the  removal  of  a  portion  of  the  sacrum.  Kraske, 
however,  in  a  contribution  to  the  Berlin  Congress  of  Surgery, 
in  1885,  was  the  first  surgeon  to  describe  in  detail  the  sacral 


TREATMENT  OF  MALIGNANT  TUMORS 


545 


Operation  for  excision  of  the  rectum.  He  reported  two  cases 
in  which  he  had  successfully  employed  this  method. 

Briefly  described,  the  original  Kraske  operation  (sacral  ex- 
cision) is  performed  as  follows : — 

The  patient  is  anesthetized  and  placed  on  the  right 
side.  Beginning  at  the  center  of  the  sacrum,  a  median  in- 
cision is  made  through  the  soft  parts  downward  to  the  anus. 
The  fibrous,  muscular,  and  ligamentous  structures  are  then  cut 
away  from  the  left  side  of  the  sacrum  and  coccyx,  below  the 


\^        /^ 


Fig.  174.— Showing  Amount  of  Bone  Removed  by  Different  Operations  in  Proc- 
tectomy. A-G,  Kraske;  A-B,  Hochenegg;  A-D,  Rydygier,  Bardenheuer, 
Levy,  and  Kraske  In  Extreme  Cases.  The  Red  Lines  Show  the  Skin  In- 
cisions of   Rhen  and  Rydygier. 

level  of  the  upper  margin  of  the  third  sacral  vertebra.  The 
coccyx  is  then  removed,  and  with  a  gouge  or  chisel  the  lower 
part  of  the  left  half  of  the  sacrum  is  cut  away  to  a  curved  line, 
beginning  at  a  point  on  the  left  side  of  the  bone,  opposite  the 
lower  margin  of  the  third  sacral  foramen,  the  detached  portion 
of  bone  including  the  fourth  sacral  foramen  (Fig.  174).  The 
rectum  is  now  freed  from  its  posterior  attachments.  The  pa- 
tient is  then  changed  to  the  lithotomy  posture,  with  the  hips 

well  elevated,  and  the  anterior  attachments  of  the  rectum  care- 
ss 


546 


DISEASES  OF  THE  RECTUM  AND  ANUS 


fully  severed.  The  peritoneal  cavity  having  been  protected 
from  infection,  the  extent  of  the  growth  is  determined  carefully. 
The  diseased  portion  of  the  gut  is  now  resected,  by  incisions 
made  in  the  healthy  tissue  transversely  through  the  bowel,  a 
short  distance  from  the  upper  and  lower  Hmits  of  the  growth. 

The  cut  ends  of  the  intestine  are  approximated  by  draw- 
ing the  upper  segment  downward  and  making  a  partial  or  com- 
plete anastomosis,  depending  upon  the  necessity  of  a  temporary 
sacral  anus.  Finally,  a  drain  is  placed  in  the  peritoneal  cavity 
and  the  wound  packed  with  iodoform  gauze.  The  operation  is 
completed  by  tightly  filHng  the  rectum  with  packing  to  keep 
the  serous  surfaces  together.  Kraske  also  suggested  that  even 
a  still  larger  part  of  the  sacrum  might  be  excised  (Fig.  174), 
if  necessary,  without  serious  consequences. 

Dr.  Willy  Meyer  was  the  first  American  surgeon  to  resect 
the  rectum  by  the  Kraske  method.  The  operation  was  per- 
formed at  the  German  Hospital,  New  York,  September  3,  1888. 
The  author  possesses  a  photograph  of  the  growth  removed. 

With  a  view  to  gaining  additional  room,  reaching  growths 
situated  in  the  upper  rectum  and  lower  sigmoid,  preserving  the 
ligamentous  and  osseous  support  of  the  pelvis,  avoiding  di- 
vision of  important  nerves,  lessening  the  danger  of  injury  to 
the  blood-vessels  supplying  the  lower  bowel,  diminishing  the 
danger  of  incontinence  and  of  fecal  fistula,  shortening  the  time 
required  for  the  operation,  and  minimizing  the  danger  of  infec- 
tion, the  Kraske  operation  has  been  modified  by  a  number  of 
surgeons.  The  most  important  changes  in  the  technic  of  the 
operation  as  suggested  and  practiced  by  these  operators  are 
briefly  described  below: — 

Bardenheuer's  Method. — In  order  to  obtain  additional  room, 
this  surgeon  divides  the  sacrum  transversely,  immediately  be- 
low the  third  sacral  foramina  (Fig.  174). 

Heincke's  Method.  —  In  this  surgeon's  modification  of  the 
Kraske  operation  the  incision  is  carried  through  the  sphincters 
and  backward  to  the  tip  of  the  coccyx.  The  lower  rectum  is 
freed  and  the  incision  then  extended  upward  in  the  median 
line  to  the  third  sacral  vertebra.  The  bone  is  now  spht  up- 
ward in  a  line  (median)  with  the  excision  to  the  inferior  margin 
of  the  third  sacral  foramina.  At  this  point  the  soft  parts  and 
bone  are  divided  on  either  side,  at  a  right  angle,  and  the  flaps 
turned  back  to  the  right  and  left,  exposing  the  rectum. 


TREATMENT  OF  MALIGNANT  TUMORS  547 

Jaennel's  Method.  —  This  operator  makes  three  incisions : 
one  transverse,  at  the  head  of  the  third  sacral  vertebra;  a  sec- 
ond transverse  at  the  sacral  cornua;  and  a  third,  longitudinal 
median  incision,  uniting  the  first  and  second.  The  flaps  are 
turned  to  either  side,  and  transverse  osteotomy  performed  at 
•  the  level  of  the  sacral  notch ;  the  coccyx  is  then  removed,  the 
sacrum  spht  in  the  middle,  and  the  bony  flaps  turned  to  the 
right  and  left,  while  the  growth  is  being  excised.  The  advan- 
tages claimed  for  this  operation  are  that  the  iliac  and  sacro- 
sciatic  ligaments  and  the  pelvic  and  trochanteric  muscles,  ves- 
sels, and  nerves  are  spared. 

Kocher's  Method. — By  means  of  a  long,  posterior  median 
cut — and  counter-incisions,  when  necessary — the  edges  and 
outer  surface  of  the  sacrum  are  quickly  freed  from  the  soft 
parts  and  ligamentous  attachments.  The  coccyx  is  now  ex- 
cised, and,  when  additional  room  is  required,  a  piece  of  the 
sacrum  is  amputated  up  to  the  fourth,  the  third,  and  in  excep- 
tional cases  even  as  high  as  the  second  sacral  foramina.  A 
strip  of  bone  is  removed,  exposing  the  nerves,  which  are 
grasped  and  held  to  one  side  while  the  sacrum  is  being  divided, 
to  avoid  injuring  them.  Kocher  hgatures  the  bowel  above  the 
growth;  the  muscular  coat  is  then  divided  with  knife  or  scis- 
sors, and  the  mucosa  with  the  thermocautery,  when  the  prox- 
imal end  of  the  gut  is  brought  down  and  sutured  to  the  pre- 
viously-denuded anus. 

Hehn-Rydyg-ier  Method.  —  This  modification  of  Kraske's 
operation  is  designated  the  "Rehn-Rydygier"  because  it  was 
first  described  by  Rehn  in  1890,  before  the  Congress  of  Ger- 
man Surgeons,  and  some  time  later  by  Rydygier,  who  was 
evidently  unaware  of  its  having  been  previously  described. 
This  modification  of  Kraske's  operation  is  ingenious.  Because 
of  its  simplicity  and  the  highly  satisfactory  results  following 
its  performance,  the  operation  has  been  received  with  almost 
universal  favor,  and  very  properly  takes  precedence  over  all 
other  methods  having  for  their  object  the  formation  of  an 
ostco-integumentary  Hap,  zvhich  is  replaced  after  resection  or 
amputation  of  the  diseased  rectum. 

The  fechnic  of  the  Rehn-Rydygier  operation  is  as  follows : 
Beginning  at  the  posterior  superior  spine  of  the  ilium,  a 
curvilinear  incision  is  made  parallel  to,  and  half  an  inch  (1.27 
centimeters)  from,  the  left  edge  of  the  sacrum  and  continued 


548  DISEASES  OF  THE  RECTUM  AND  ANUS 

to  the  tip  of  the  coccyx,  from  which  point  it  is  carried  down- 
ward in  the  median  Hne  to  or  nearly  to  the  anus  (Fig.  174), 
as  the  case  may  require.  The  left  sacro-sciatic  ligaments,  small 
and  large,  are  exposed  and  severed,  and  the  anterior  surface 
of  the  sacrum  freed  from  its  attachments.  Beginning  at  the 
first  cut,  a  transverse  incision  is  made  entirely  across  the 
sacrum  through  the  soft  parts,  just  below  the  third  sacral 
foramina,  and  the  bone  chiseled  through  at  this  point  (Fig. 
174).  The  osteo-integumentary  lid  thus  formed  is  raised  and 
turned  back  to  the  right,  permitting  free  approach  to  the  rec- 
tum.    After  the  growth  has  been  excised  the  lid  is  replaced. 

Levy's  Method.  —  The  soft  parts  down  to  the  sacrum  are 
divided  by  a  transverse  cut  one  and  a  half  inches  (3.81  centi- 
meters) above  the  cornua  of  the  coccyx;  the  ends  of  this  in- 
cision are  then  carried  downward  in  a  direction  parallel  with 
the  fibers  of  the  gluteus  maximus  muscle  to  a  point  two  inches 
(5.08  centimeters)  from  the  tuber  ischii;  the  fourth  sacral 
foramen  and  sacro-sciatic  ligaments  on  both  sides  are  brought 
into  view  by  separating  the  gluteal  fibers ;  the  latter  are  now 
divided  on  a  director  to  obviate  the  danger  of  wounding  the 
pudic  vessels  and  nerve ;  the  anterior  sacral  attachments  are 
loosened  sufficiently  to  admit  a  chain-saw,  when  the  bone  is 
severed  through  from  within  outward  on  a  line  with  the  trans- 
verse incision  (Fig.  174) ;  the  V-shaped  flap  is  then  freed  at 
its  upper  end  and  turned  down  over  the  anus,  bringing  the 
rectum  into  view.  After  placing  ligatures  on  either  side  of  the 
tumor.  Levy  pushes  the  healthy  bowel  of  either  end  beyond 
the  ligature  and  sutures  the  rectum  half-way  around,  before 
the  growth  is  resected.  The  injury  to  the  sacrum  is  repaired 
immediately  or  at  a  second  operation.  This  operation  has  not 
met  with  much  favor,  because  the  results  following  it  have  not 
been  so  good  as  those  of  the  Kraske  operation,  and,  further, 
because  it  does  not  give  sufficient  room  to  enable  the  operator 
to  do  his  work  quickly. 

Hegar's  Method. — This  operation  is  the  reverse  of  Levy's. 
Beginning  at  the  anus,  incisions  are  carried  upward  on  either 
side  of  the  coccyx  and  sacrum  to  a  level  with  the  inferior 
margin  of  the  third  sacral  foramina ;  a  chain-saw  is  placed  be- 
neath the  bone,  and  it  is  divided  at  this  point.  The  osteo- 
integumentary  flap  thus  formed  is  turned  upward,  and  is 
replaced  after  the  rectum  has  been  resected. 


TREATMENT  OF  MALIGNANT  TUMORS  549 

Walker's  Method. — The  incisions  are  the  same  as  Hegar's, 
but  the  sacrum  is  divided  only  part-way  through  in  front,  so 
that  the  periosteum  is  left  to  act  as  a  hinge,  when  the  skin- 
and-bone  flap  is  turned  upward.  After  resection  of  the  growth, 
anastomosis  is  made  with  the  Murphy  button. 

Roux's  Method.  —  This  operation  does  not  differ  from  the 
one  just  described,  except  that  the  soft  parts  are  divided  on 
the  right  side  of  the  sacrum  and  the  osteo-integumentary  Hap  is 
turned  to  the  left. 

Borelius's  Method.  —  The  patient  is  placed  on  the  right 
side,  with  the  hips  elevated.  The  soft  parts  are  then  divided 
by  an  incision  from  the  tip  of  the  coccyx  to  the  center  of  the 
sacrum,  and  a  second  incision  of  sufficient  length  is  made  from 
the  beginning  of  the  first  along  the  lower  border  of  the  right 
gluteus  maximus  muscle.  The  integumentary  flap  on  the  right 
side  is  freed  from  the  bone  and  held  back  while  the  right  sacro- 
sciatic  ligaments  are  severed.  The  soft  parts  to  the  left  of  the 
incision  are  then  sufflciently  freed  from  the  bone  and  retracted, 
while  the  sacrum  is  divided  with  the  chisel  in  an  oblique  line, 
extending  from  below  the  third  sacral  foramen  on  the  left 
through  the  fourth  sacral  foramen  on  the  right.  The  bone-flap 
is  then  freed  and  turned  to  the  left,  while  the  diseased  portion 
of  the  bowel  is  removed. 

Zuckerkandl  and  Wolfler  do  not  sacrifice  the  bony  struct- 
ures, but  remove  the  growth  through  long  vertical  incisions, 
carried  through  the  soft  parts  on  the  left  (Zuckerkandl)  and 
right  (Wolfler)  sides  of  the  bony  line. 

The  above  modifications  have  dealt  principally  with  the 
jlififerent  methods  of  approaching  the  grozvth.  Those  to  follow 
give  the  various  ways  suggested  for  handling  the  bowel  after 
the  neoplasm  has  been  extirpated : — 

Hochenegf 's  Method.  —  With  the  object  of  averting  the 
formation  of  fecal  fistulas  following  resection  of  the  rectum, 
and  also  to  preserve  the  sphincter-muscle,  Hochenegg  devised 
his  "pull-through"  method.  This  consists  of  denudation  of  the 
mucosa  of  the  anal  segment  and  bringing  the  proximal  end  of 
the  gut  through  the  anal  segment  down  to  the  anus,  where  it 
is  sutured  to  the  skin.  He  reports  good  results  from  this  pro- 
cedure in  cases  in  which  it  has  been  feasible.  The  author  has 
resorted  to  Hochenegg's  method  of  dealing  with  the  bowel  in 


550  DISEASES   OF  THE   RECTUM  AND  ANUS 

a  number  of  cases,  and  has  been  much  pleased  with  the  results 
obtained. 

Morestin's  Methcd.  —  The  lower  half-inch  (1.27  centime- 
ters) of  the  proximal  end  of  the  bowel  is  denuded  of  mucosa; 
the  operation  is  now  reversed  and  the  upper  half-inch  (1.27 
centimeters)  of  the  lower  segment  is  denuded  of  the  muscular 
layer.  The  bowel  is  then  spliced  by  pulling  the  former  down 
over  the  latter,  like  a  cuff,  where  it  is  anchored  by  a  sufficient 
number  of  sutures.  This  method  of  uniting  the  gut  has  thus 
far  failed  to  meet  with  much  favor,  and  the  writer  has  been 
unable  to  find  a  published  case  where  it  has  been  successfully 
employed.  Morestin  held  that  the  fecal  incontinence  follow- 
ing resection  is  due  to  injury  of  the  nerves,  and  advises  ampu- 
tation and  suturing  of  the  proximal  end  of  the  bowel  to  the 
anus  wherever  this  is  possible. 

Keen's  Method.  —  Keen  establishes  a  preliminary  colos- 
tomy, and,  after  extirpating  the  growth  and  lower  rectum  by 
the  sacral  route,  he  closes  the  proximal  end  of  the  bowel,  drops 
it  back  into  the  pelvis,  and  closes  the  posterior  wound,  com- 
pletely obliterating  the  space  formerly  occupied  by  the  rectum. 
He  has  reported  two  cases  successfully  treated  in  this  manner, 
and  says  that  the  mucus  secreted  by  the  blind  end  of  the  bowel 
is  discharged  through  the  artificial  anus. 

Lange's  Method. — In  order  to  permit  the  anal  segment  to 
be  drawn. upward  after  resection  and  anastomosis,  and  thus 
diminish  the  tension  and  danger  of  the  stitches  giving  way, 
Lange  makes  an  incision  around  the  anus  between  the  orifice 
and  the  tuber  ischii,  sufficiently  deep  to  divide  the  anterior 
fibers  of  the  levator  ani,  thus  allowing  the  anus  to  retract  up- 
ward. In  his  hands  this  operation  has  been  successful  in  two 
cases. 

Gersuny's  Method. — After  amputation  of  the  rectum  above 
the  growth,  Gersuny  twists  the  bowel  (180  to  275  degrees) 
upon  its  long  axis,  before  suturing  it  to  the  skin.  According 
to  the  reports  of  the  originator  of  this  method,  this  tends  to 
prevent  incontinence  by  offering  an  elastic  resistance  to  the 
descent  of  the  feces.  In  the  author's  experience,  this  proced- 
ure has  been  of  little  service  in  averting  partial  incontinence, 
because  the  obstruction  produced  is  not  always  sufficient  to 
prevent  the  escape  of  feces  at  inopportune  times.  However, 
twisting  of  the  bowel,  as  recommended  by  Gersuny,  requires 


TREATMENT  OF  MALIGNANT  TUMORS 


551 


but  a  few  seconds,  adds  no  danger  to  the  operation,  and  should 
be  done  unless  the  tension  of  the  gut  is  too  great. 

Willems's  Method. — To  prevent  or  relieve  incontinence  fol- 
lowing excision  of  the  rectum  and  other  operations  in  which 
the  sphincter-muscle  has  been  destroyed,  Willems  has,  in  sev- 
eral cases,  successfully  resorted  to  separation  of  the  fibers  of 
the  gluteus  maximus  muscle,  pulling  the  end  of  the  bowel 
through  between  the  fibers,  and  suturing  it  to  the  skin.  This 
operation  is  difficult  to  perform,  and  the  results  obtained  are 
no  better  than  those  secured  by  Gersuny's  method. 

Inferior  Proctectomy  (Lisfranc's  Operation,  Perineal  Excision 
of  the  Rectum).  —  Inferior  proctectomy  is  performed  by  the 


Fig.  175.— Inferior  Proctectomy.     Herbert  W.  Allingliam's  Preliminary  Incisions. 


author  as  follows :  The  patient,  prepared  and  anesthetized,  is 
placed  in  the  lithotomy  position,  with  legs  flexed  upon  the  ab- 
domen and  buttocks  projecting  over  the  end  of  the  table.  The 
external  parts  and  the  rectum  are  thoroughly  cleansed,  and,  if 
the  patient  is  a  male,  a  sound  or  silver  catheter  is  introduced 
into  the  bladder  as  a  guide  to  guard  against  injuring  the  deep 
urethra.  The  sphincter-muscle  is  divulsed  with  the  thumbs  and 
the  anus  everted  with  forceps.  The  bowel  is  now  completely 
divided  by  a  circular  incision  made  immediately  above  the  ex- 
ternal sphincter,  and  the  rectum  above  the  incision  freed  suffi- 
ciently to  be  grasped  with  four  long-handled,  T-shaped  forceps, 
one  on  each  of  its  sides,  and  held  by  an  assistant. 

In   order  to   gain   the   necessary   room   for   dissection,   a 


552 


DISEASES  OF  THE  RECTUM  AND  ANUS 


probe-pointed  bistoury  is  pushed,  with  its  flat  side  toward  the 
bowel,  upward  for  a  distance  of  two  or  three  inches  (5.08  or 
7.G2  centimeters)  through  the  cellular  tissue  immediately  be- 
hind the  rectum;  the  knife  is  then  directed  backward  and  with- 
drawn, dividing  in  one  stroke  all  the  soft  parts,  including  the 
sphincter,  back  to  the  tip  of  the  coccyx,  and  leaving  a  deep, 
triangular  wound  (Fig.  175).^  Allingham  considers  this  cut  as 
the  "key"  to  the  operation. 

The  traction-forceps  are  now  grasped  in  the  left  hand  and 
the  rectum  held  first  to  one  side,  then  to  the  other,  while  it  is 
freed  from  its  attachments  to  the  surrounding  structures  by 


Fig.   176.— Manner  of  Isolating  tlie  Bowel. 


dissections  made  with  the  finger,  handle  of  the  scalpel,  or 
blunt  scissors  (Fig.  176).  Sharp-pointed  scissors  or  the  knife 
should  not  be  used  for  this  purpose,  owing  to  the  danger  of 
button-holing  the  bowel,  urethra,  or  vagina.  The  rectum  can 
be  loosened  from  its  posterior  more  rapidly  than  from  its  ante- 
rior attachments,  because  of  its  close  relations  in  front  to  the 
bladder,  urethra,  and  prostate  or  vagina. 

When  the  dissections  have  been  carried  above  the  growth 
(Figs.  176  and  177),  the  bowel  is  drawn  downward  as  far  as 
possible  and  amputated,  the  proximal  end  being  grasped  with 

1  Pigs.  175,  176,  and  177  were  used  by  Mr.  Herbert  W.  Allingham  in  the  chapter 
written  by  him  on  "Cancer  of  the  Rectum"  for  the  previous  edition  of  this  work. 


TREATMENT  OF  MALIGNANT  TUMORS 


553 


forceps  to  prevent  retraction.  Spurting  vessels  are  ligated,  and 
oozing  arrested  by  packing  the  wound  with  gauze  compresses 
wrung  out  of  hot  water.  If  possible,  the  proximal  end  of  the 
bowel  is  now  brought  down  and  united  to  the  distal  end  by  inter- 
rupted catgut  or  silk  sutures  passed  through  the  entire  thick- 
ness of  the  gut-wall.  The  author  has  also  successfully  employed 
Hochenegg's  method  of  denuding  the  mucosa  of  the  anal  seg- 
ment, pulhng  the  gut  down  through  the  latter,  and  suturing  it 
to  the  skin  about  the  anus.  When  feasible,  either  of  these 
methods  preserves  the  sphincter-muscle  and  thereby  averts 
incontinence.  The  ends  of  the  divided  sphincter-muscle  are  ap- 
proximated by  means  of  buried  catgut  sutures,  and  a  gauze 


Fig.  177. — Rectum  Freed  from  its  Surroundings.     Ready  to  be  Amputated. 


drain  is  inserted  in  the  posterior  wound,  which  is  then  closed  by 
a  continuous  suture.  Primary  union  is  seldom  obtained,  owing 
to  tension,  and  consequently  more  or  less  retraction  follows. 

In  most  instances,  especially  when  a  large  growth  has  been 
removed,  it  is  impossible  to  bring  the  end  of  the  rectum  down 
to  the  anal  segment.  In  such  cases  the  bowel  should  be  packed 
with  gauze  and  the  entire  wound  left  to  heal  by  granulation. 
Dressings  are  now  applied  and  held  in  place  by  a  properly- 
adjusted  T-bandage.  The  entire  operation  should  not  require 
more  than  twenty  or  thirty  minutes. 

When  the  growth  is  sufficiently  low  down  to  involve  the 
sphincter-muscle,  the  circular  incision  is  made  through  the  skin 


554  DISEASES  OF  THE  RECTUM  AND  ANUS 

at  least  half  an  inch  (1.27  centimeters)  to  the  outer  side  of  the 
anal  margin;  the  rectum  is  then  isolated,  the  diseased  portion 
amputated,  and  the  end  of  the  bowel  drawn  down  and  sutured 
to  the  skin. 

Inferior  proctectomy  is  performed  only  when  the  growth 
is  in  the  lower  three  inches  (7.62  centimeters)  of  the  rectum. 
For  this  reason  the  peritoneum  is  rarely  injured.  Should  such 
an  accident  occur,  however,  the  life  of  the  patient  is  not  greatly 
endangered,  provided  the  peritoneal  wound  is  immediately 
closed  with  fine  catgut  or  the  cavity  drained  with  gauze. 

The  patient  should  be  kept  quiet  and  restricted  to  a  light 
diet  until  after  the  first  week.  The  dressings  are  removed  on 
the  fourth  day  and  an  action  of  the  bowels  secured.  Thereafter 
the  rectum  should  be  emptied  every  two  or  three  days,  and 
then  irrigated.  Fresh  dressings  should  be  applied  after  each 
stool  and  as  often  as  they  become  soiled  by  the  discharge. 
Owing  to  retraction  and  cicatrization,  the  lumen  of  the  bowel 
becomes  narrowed  in  most  of  these  cases.  To  prevent  this, 
the  finger  or  a  rubber  bougie  should  be  introduced  into  the 
bowel  at  intervals  of  a  few  days  for  at  least  six  months  after 
the  operation.  Cicatrization  not  infrequently  draws  the  prox- 
imal end  of  the  rectum  downward  toward  the  anal  segment, 
and,  when  the  interval  is  narrow,  the  mucosa  may  become  con- 
tinuous. In  one  case  prolapse  of  the  mucous  membrane  is  said 
to  have  followed  the  operation. 

The  following  are  the  chief  disadvantages  of  inferior  proc- 
tectomy : — 

1.  It  is  applicable  only  to  a  small  percentage  of  malignant 
tumors  of  the  rectum  which  are  located  near  the  anus. 

2.  Resection  and  end-to-end  anastomosis  are  rarely  pos- 
sible by  this  procedure. 

3.  Last,  the  working  space  is  so  limited  that,  when  the 
growth  proves  more  extensive  than  was  anticipated  and  serious 
complications  are  encountered  (injury  to  the  bladder,  etc.),  the 
operation  must  frequently  be  abandoned  and  the  neoplasm  de- 
livered by  the  vaginal  or  sacral  route. 

Superior  Proctectomy  (Kraske's  Operation;  Sacral  Excision  of 
the  Rectum).  —  The  term  superior  proctectomy  is  applied  to  all 
operations  of  excision  and  resection  of  the  rectum  wherein  the 
bowel  is  approached  from  behind  and  dissected  out  from  above 
downward.     In  order  to  accomplish  this  object  it  is  sufficient, 


TREATMENT  OF  MALIGNANT  TUMORS  555 

in  some  cases,  to  remove  only  the  coccyx  (through  a  posterior 
median  incision)  ;  in  others  a  portion  of  the  sacrum  must  be 
included,  or  an  osteo-integumentary  flap  formed  and  replaced 
after  the  bowel  is  excised.  When  the  sphincter  is  not  involved, 
it  is  desirable  to  preserve  this  muscle;  if,  however,  the  disease 
extends  to  the  anus,  the  lower  rectum  must  be  amputated  and 
a  sacral  anus  established.  For  these  reasons  no  one  method 
of  performing  superior  proctectomy  is  practicable  in  all  cases. 
On  the  contrary,  the  operation  must  be  varied  to  suit  the  case 
under  consideration. 

The  author  performs  the  operation  after  the  following 
method,  which  embraces  many  of  the  practical  points  suggested 
by  Kraske  and  other  surgeons,  who  have  modified  his  opera- 
tion, together  with  a  few  of  his  own : — 

The  patient,  previously  prepared  and  anesthetized,  is 
placed  on  a  low  table,  on  his  left  side,  with  legs  flexed  upon 
the  abdomen,  body  inclined  to  the  right  until  almost  face  down- 
ward, and  the  pelvis  raised  by  means  of  sand-bags.  The  outer 
parts  are  thoroughly  scrubbed  and  cleansed,  and  the  rectum 
irrigated,  dried,  and  packed  (or  the  anus  sutured)  loosely  with 
gauze  to  prevent  soiling  and  infection  of  the  wound. 

Beginning  at  the  posterior  superior  spine  of  the  ilium  on 
the  left,  an  incision  is  made  just  external  to,  and  following  the 
curve  of  the  left  border  of  the  sacrum  and  continued  downward 
to  the  tip  of  the  coccyx.  From  this  point  it  is  carried  down 
in  the  median  Hue  to  the  border  of  the  sphincter-muscle.  A 
second  incision  is  then  made  through  the  soft  parts  just  below 
the  lower  margin  of  the  third  sacral  foramina,  extending  from 
the  first  cut  across  the  sacrum  and  a  little  beyond  the  right  edge 
of  the  bone.  The  flap  thus  formed  is  dissected  up  from  the 
bone  (unless  an  osteo-integumentary  flap  is  to  be  made)  by  a 
few  rapid  strokes  of  the  knife  and  turned  back  to  the  right, 
exposing  the  sacrum  and  coccyx. 

The  tip  of  the  coccyx  is  freed  and  then  grasped  and  lifted 
up  with  strong,  spiked  forceps,  held  in  the  left  hand.  The 
lateral  attachments  of  the  sacrum  and  coccyx,  both  muscular 
and  ligamentous,  including  the  lesser  and  a  portion  of  the 
greater  sacro-sciatic  ligaments,  are  rapidly  divided  up  to  the 
transverse  skin  incision  by  means  of  the  author's  heavy,  blunt 
scissors. 

The  soft  parts  are  stripped  off  the  anterior  surface  of  the 


556  DISEASES  OF  THE  RECTUM  AND  ANUS 

coccyx  and  lower  portion  of  the  sacrum  with  the  handle  of  the 
scalpel  or  the  finger,  care  being  taken  to  avoid  injury  to  the 
sacral  vessels  and  consequent  hemorrhage.  The  lower  part  of 
the  sacrum  with  the  coccyx  is  now  removed  by  dividing  the 
sacrum  from  left  to  right  with  bone-forceps  just  below  the  level 
of  the  lower  margin  of  the  third  sacral  foramina,  which  exposes 
the  rectum.  Spicules  of  bone  should  be  removed  and  a  pad  of 
gauze  placed  over  the  sharp  end  of  the  bone  to  protect  the  hand 
from  injury  while  separating  the  rectal  attachments  from  the 
hollow  of  the  sacrum.  If  the  bone  bleeds  freely,  pressure  may 
be  made  over  the  gauze  compresses  by  an  assistant. 

The  exposed  rectum  is  now  rapidly  separated  from  its 
lateral  attachments  with  the  finger  and  handle  of  the  scalpel. 
More  time  and  care  are  necessary  to  free  the  bowel  from  its 
anterior  attachments  because  of  the  insertion  of  the  levator  ani 
muscle  and  its  close  proximity  to  the  vagina,  urethra,  and  pros- 
tate. Blunt  scissors  are  usually  required  to  dissect  the  bowel 
from  the  muscles  and  other  structures  in  front.  For  this  reason 
a  sound  should  be  introduced  into  the  urethra  and  the  finger 
inserted  into  the  vagina  from  time  to  time,  in  order  to  ascertain 
how  close  the  dissections  are  being  carried  to  these  organs  and 
to  serve  as  a  guide  to  avoid  injuring  them. 

The  rectum  is  then  separated  from  its  sacral  connections 
to  a  safe  distance  above  the  upper  margin  of  the  growth,  which 
is  determined  by  roHing  the  bowel  between  the  fingers.  While 
making  the  posterior  dissections,  extreme  care  must  be  taken 
not  to  injure  the  sacral  or  the  hemorrhoidal  vessels,  in  order 
to  avoid  troublesome  hemorrhage  and  to  preserve  the  nutrition 
of  the  rectum  after  the  operation.  If  blunt  scissors  are  used, 
they  should  be  directed  backward  toward  the  sacrum  and  the 
dissections  carried  as  near  the  bone  as  possible.  After  the 
bowel  has  been  completely  isolated  sufficiently  high  up  the 
packing  is  removed  from  the  rectum,  which  is  again  thoroughly 
cleansed  and  dried. 

Gauze  is  then  placed  under  the  bowel  to  protect  the  wound. 
The  diseased  portion  is  resected  (between  ligatures  placed 
above  and  below  the  growth),  the  incisions  being  made  at  least 
half  an  inch  (1.27  centimeters)  from  the  upper  and  lower  limits 
of  the  neoplasm.  The  proximal  end  of  the  bowel  is  then 
brought  down  and  united  to  the  distal  segment  by  circular 
enterorrhaphy  (Fig.  17S).     For  this  purpose  ordinary  sewing- 


TREATMENT  OF  MALIGNANT  TUMORS 


557 


needles  and  black  silk  thread  are  used.  The  Murphy  button 
may  be  employed  when  the  resection  is  high  up,  but  lower 
down,  where  the  bowel  is  devoid  of  peritoneum,  union  will  not 
follow  its  use. 

Bleeding-,  which  is  profuse  at  first,  diminishes  as  the  opera- 
tion proceeds ;  but  few  vessels  require  to  be  ligated  except 
those  cut  when  the  bowel  is  divided.  Troublesome  oozing-  can 
be  readily  controlled  with  gauze  compresses  wrung  out  of  hot 
water  and  pressed  firmly  into  the  wound. 


Fig.  178.— Showing  Bony  Integumentary  Flap  Held  Bacli  while  the  Growth 
is  Removed  and  an  End-to-End  Anastomosis  is  Made  in  Superior  Proc- 
tectomy. 

When  possible,  the  growth  should  be  removed  zvithout 
opening  the  peritoneal  cavity.  In  most  cases,  however,  owing 
to  the  extent  of  the  disease  or  its  high  location,  the  peritoneum 
must  be  divided  in  order  to  resect  the  growth  and  liberate  the 
bowel  sufficiently  to  bring  the  proximal  end  down  to  unite  it 
to  the  distal.  To  accompHsh  this  it  sometimes  suffices  to  sever 
the  lateral  peritoneal  attachments ;  but  it  may  be  necessary  to 
separate  the  peritoneum  from  all  sides  of  the  rectum.  In  such 
cases  the  mesorectum  binding  it  to  the  sacrum  should  be  divided 
as  far  as  possible  from  the  bozvel,  in  order  to  avoid  severing  the 


558 


DISEASES  OF  THE  RECTUM  AND  ANUS 


nutrient  vessels.  After  the  anastomosis  has  been  completed, 
if  the  field  of  operation  is  clean,  the  peritoneum  should  be 
stitched  to  the  serous  coat  of  the  bowel;  if  there  is  danger 
of  infection,  the  peritoneal  cavity  may  be  drained  with  gauze. 
The  wound  is  now  irrigated  and  gauze  placed  about  the 
bowel  to  insure  free  drainage.  The  skin-flap  is  replaced  and 
sutured,  allowing  space  for  the  gauze  drains.  The  rectum  is 
loosely  packed  with  antiseptic  gauze  to  protect  the  wound 
within  the  bowel,  and  dressings  are  applied  to  the  external 


Fig.   179.— Showing   Method   of  Amputating  the   Rectum   After  it  has   been 
Freed  from  its  Attachments  in  Superior  Proctectomy. 


wound  and  secured  with  a  T-bandage.  The  patient  is  placed  in 
bed,  with  instructions  to  the  nurse  to  keep  him  quiet,  admin- 
istering opiates,  if  necessary.  When  the  growth  is  low  and  it 
can  be  extirpated  by  removing  the  coccyx  only,  the  writer 
prefers  the  posterior  median  incision  of  Kocher. 

When  it  is  desirable  to  form  an  osteo-integumentary  flap,  the 
same  preliminary  incisions  are  made.  The  ligamentous  and 
muscular  attachments  are  severed  on  the  left  side  of  the  sacrum 
and  coccyx  up  to  the  transverse  skin  incision  and  also  from  the 
tip  and  anterior  surface  of  the  coccyx.    The  sacrum  is  divided 


TREATMENT  OF  MALIGNANT  TUMORS  559 

on  a  line  just  below  the  third  sacral  foramina  as  before  de- 
scribed, and  the  bone  and  attached  soft  parts  turned  back  to  the 
right  (Fig.  178)  and  held  by  an  assistant.  The  rectum  is  then 
amputated  or  resected,  after  which  the  flap  is  restored  and  su- 
tured. This  temporary  resection  of  the  sacrum  is  not  always 
desirable,  because  of  the  great  difficulty  of  draining  the  wound 
after  the  bony  flap  has  been  replaced,  and,  unless  the  surgeon 
is  confident  that  there  is  little  danger  of  infection,  the  bone 
should  not  be  restored. 

Owing  to  this  serious  difhculty  of  guarding  against  infec- 
tion after  temporary  resection  of  the  bone,  not  infrequently, 
the  author  permanently  removes  the  coccyx  and  lower  portion 
of  the  sacrum  (Figs.  179  and  180).  His  patients  have  not  com- 
plained of  an}^  very  great  inconvenience  from  the  deformity 
caused  by  permanent  removal  of  these  bony  structures,  but  at 
the  same  time  he  considers  the  iimiecessary  removal  of  any 
part  of  the  pelvic  support  inadvisable. 

The  method  of  dealing  with  the  bowel  after  the  growth  has 
been  excised  varies  greatly  in  different  cases,  depending  upon 
the  location  and  extent  of  the  disease.  In  uniting  the  ends  of 
the  bowel  by  circular  enterorrhaphy  as  above  described,  the 
surgeon  frequently  meets  with  great  difficulty  iii  placing  the 
posterior  stitches,  because  of  the  tension  upon  the  bowel  and 
the  limited  space  in  which  to  work.  To  overcome  this  disad- 
vantage the  author  has  in  some  cases  employed  the  method  sug- 
gested by  Flochenegg:  invaginating  the  lower  segment  of  the 
bowel  through  the  anus  and  drawing  the  proximal  through  it 
sufficiently  to  permit  the  ends  of  the  rectum  to  be  approximated 
and  sutured,  after  which  the  bowel  is  returned.  Where  this  is 
feasible  the  anastomosis  can  be  made  more  quickly  and  accu- 
rately than  by  the  usual  method.  Circular  enterorrhaphy  is 
very  often  followed  by  the  formation  of  a  posterior  fecal  fistula. 
To  obviate  this  complication  the  writer  has  frequently  resorted 
to  Hochenegg's  plan,  known  as  the  "pull-through"  method, 
which  consists  in  denuding  the  mucosa  of  the  anal  segment 
and  pulling  the  proximal  end  down  through  the  denuded  gut, 
where  it  is  sutured  to  the  skin  around  the  anus.  This  pro- 
cedure does  not  interfere  with  the  function  of  the  sphincter- 
muscle. 

When  a  malignant  growth  involves  so  much  of  the  bowel 
that  its  removal  renders  an  end-to-end  anastomosis  impossible, 


560 


DISEASES  OF  THE  RECTUM  AND  ANUS 


or  prevents  the  proximal  end  of  the  gut  bemg  brought  down 
and  stitched  around  the  anus,  a  sacral  anus  should  be  formed 
by  stitching  the  proximal  end  to  the  margin  of  the  wound 
below  the  end  of  the  sacrum  (Fig.  180).  This  is  a  quick  and 
safe  procedure. 

When  the  disease  extends  downward  to  the  anal  margm, 
it  is  impossible  to  preserve  the  sphincter-muscle.  In  such  cases 
the  preliminary  incision  is  carried  down  and  made  to  encircle 
the  anus  as  for  inferior  proctectomy;  the  rectum  is  then  dis- 
sected out,  amputated  well  above  the  growth  (Fig.  179),  and 


Fig.   180.— Showing  Appearance  of  Wound   and  Location   of  the   Sacral  Anu3 
After  Superior  Proctectomy. 

the  proximal  end  of  the  bowel  brought  down  and  sutured  to  the 
skin  around  the  circular  incision.  When  this  is  not  possible, 
a  sacral  anus  is  formed  (Fig.  180).  If  the  end  of  the  gut  is 
encircled  with  a  purse-string  suture  of  catgut  before  attaching 
it  to  the  skin,  fewer  stitches  are  required  and  a  smaller  opening 
is  left. 

The  incontinence  which  invariably  follows  extirpation  of  the 
sphincter-muscle  may  be  lessened  in  degree,  but  not  entirely 
averted,  by  twisting  the  bowel,  as  suggested  by  Gersuny,  or 
by  bringing  it  out  between  the  fibers  of  the  gluteus  maximus 


TREATMENT  OF  MALIGNANT  TUMORS  561 

muscle  and  uniting  it  to  the  skin,  as  recommended  by  Willems, 
Jaennel,  and  Witzel. 

In  order  to  prevent  the  straining  incident  to  defecation, 
to  lessen  the  danger  of  infection  of  the  wound  from  the  feces, 
and  to  avert  the  formation  of  a  fecal  fistula,  Schede,  Quenu, 
Keen,  and  many  other  leading  operators  advocate  preliminary 
colostomy,  and  amputation  or  resection  of  the  growth  at  a  later 
date.  The  author  is  heartily  in  accord  with  these  surgeons,  and 
would  advise  preliminary  colostomy,  especially  in  those  in- 
stances in  which  the  growth  is  extensive,  located  high  up,  and 
leaves  a  considerable  distance  between  the  ends  of  the  bowel 
when  removed.  This  operation  is  also  indicated  in  cases  in 
which  it  is  desirable  to  extirpate  the  entire  rectum.  The  mor- 
tality, immediate  and  remote,  is  certainly  less  when  the  radical 
operation  is  preceded  by  the  establishment  of  an  artificial  anus. 

The  after-treatment  following  posterior  proctectomy  does 
not  differ  materially  from  that  already  given  for  inferior  proc- 
tectomy. The  diet  should  be  light  for  the  first  few  days  and  the 
feces  kept  soft.  Most  important  of  all  is  proper  drainage  of  the 
wound. 

The  author  would  emphasize  that  success  in  superior  proc- 
tectomy depends  mainly  upon  observance  of  the  following  points 
in  technic : — 

1.  Preserve  the  nerves,  and  ligamentous  and  muscular  at- 
tachments as  far  as  possible,  and  in  order  to  prevent  pelvic 
deformity  remove  only  the  necessary  amount  of  bone. 

2.  If  possible,  leave  the  external  sphincter  intact,  to  pre- 
vent incontinence. 

3.  When  isolating  the  rectum  avoid  hemorrhage  and  pro- 
tect the  nutrient  vessels  by  severing  the  mesorectum  close  to 
the  sacrum. 

4.  Diminish  the  danger  of  peritonitis,  where  feasible,  by 
extirpating  the  growth  without  entering  the  peritoneal  cavity. 

5.  Free  the  bowel  sufficiently  to  avoid  tension,  and  accu- 
rately approximate  the  upper  and  lower  end;  otherwise  leak- 
age may  take  place  between  the  sutures  or  the  stitches  may 
cut  out,  causing  fecal  fistula. 

6.  Thorough  asepsis  should  be  observed  throughout  the 
operation.  The  operative  field  should  be  kept  clean  and  the 
peritoneal  cavity  protected  by  stitching  up  the  anus  or  packing 
the  lower  rectum  with  antiseptic  gauze.    The  finger  should  be 


562  DISEASES  OF  THE  RECTUM  AND  ANUS 

introduced  into  the  bowel  only  when  absolutely  necessary,  and, 
when  feasible,  the  peritoneal  cavity  should  be  closed  before  the 
bowel  is  opened. 

Y.  When  an  osteo-integumentary  flap  has  been  formed,  if 
there  is  any  reason  to  believe  that  the  wound  has  been  infected, 
it  should  be  replaced,  but  not  sutured. 

8.  Provide  thorough  drainage  for  every  part  of  the  wound. 

The  following  are  a  few  of  the  beneficial  results  which 
may  be  derived  from  proctectomy,  either  superior  or  inferior : — 

1.  It  effects  a  cure  in  16  per  cent,  of  properly  selected 
cases. 

2.  In  case  of  recurrence  patients  usually  live  considerably 
longer  than  if  the  operation  had  not  been  performed. 

3.  As  a  palliative  procedure,  it  relieves  obstruction ;  stops 
straining,  diarrhea,  bleeding,  and  odor ;  does  away  with  press- 
ure pains,  and  relieves  the  pruritus  incident  to  the  excoriations 
caused  by  the  irritating  discharge  passing  over  the  parts. 

4.  It  encourages  a  class  of  sufferers,  who  otherwise  would 
have  been  condemned  to  a  miserable  existence  and  a  speedy 
death,  to  hope  for  a  new  lease  of  life. 

5.  The  sequels  following  the  operation  are  sometimes  an- 
noying, but  the  pain  from  this  source  does  not  begin  to  com- 
pare with  the  suffering  which  would  have  ensued  had  the 
operation  not  been  performed. 

6.  The  mortality  (21  per  cent.)  following  the  operation 
is  not  sufficiently  high  to  warrant  the  timid  surgeon  in  refusing 
aid,  other  than  palliative  measures,  to  these  suffers  who,  were 
they  in  the  hands  of  a  bolder  operator,  would  be  given  a  chance 
for  their  lives. 

Mortality  and  Operability  of  Inferior  and  Superior  Proctectomy^ 
— A  study  of  the  mortality  statistics  of  any  operation  collected 
from  various  sources  is  always  confusing  and  frequently  un- 
satisfactory. This  is  especially  true  of  the  radical  extirpation 
of  malignant  neoplasms  of  the  rectum,  and  for  the  following 
reasons:  (a)  one  operator  carefully  selects  his  cases  for  opera- 
tion, while  another  operates  on  nearly  all  rectal-cancer  patients 
who  apply  to  him  for  treatment;  (h)  many  surgeons  embrace 
in  their  statistics  the  mortality  of  both  superior  and  inferior 
proctectomy,  but  fail  to  state  the  number  of  cases  operated 
upon  by  each  method  and  the  relative  mortality;  (c)  some 
authors  include  in  their  statistic  data  only  those  deaths  occur- 


TREATMENT  OF  MALIGNANT  TUMORS  563 

ring  on  the  operating-table  or  shortly  following  the  operation, 
while  others  include  both  the  immediate  and  remote  mortality; 
{d)  finally,  the  operator  frequently  omits  to  state  whether  the 
growth  was  removed  by  resection  or  amputation,  and  this  is 
an  important  point,  because  the  mortality  of  the  former  is  much 
greater  than  that  of  the  latter. 

For  the  above  reasons  the  author  will  not  attempt  to 
analyze  the  abundant  material  collected  by  him  to  determine 
the  mortality  of  rectal  excision  and  resection.  The  results  ob- 
tained by  some  of  the  most  expert  operators  in  this  field  of 
surgery  will  be  given,  however,  to  show  the  mortality  of  radical 
extirpation  of  malignant  growths  of  the  rectum  by  experienced 
operators,  and  also  the  percentage  of  these  cases  considered 
operable  by  these  authorities. 

Before  the  advent  of  antisepsis  and  asepsis  the  mortality 
of  inferior  (perineal)  proctectomy  was  about  25  per  cent.,  but 
since  this  epoch-making  period  the  death-rate  of  this  operation 
has  been  materially  reduced,  and  at  the  present  time  it  is 
approximately  but  7.5  per  cent,  in  the  hands  of  expert  sur- 
geons. Where  the  operation  is  performed  by  inexperienced 
persons  or  those  who  disregard  the  principles  advanced  by 
Lister,  the  percentage  of  mortality  is  considerably  higher. 

The  average  mortality  of  the  Kraske  operation  (superior 
proctectomy)  and  of  its  various  modifications  is  considerably 
higher  than  that  of  inferior  proctectomy:  in  round  numbers 
about  21  per  cent.  The  mortality  of  this  operation,  as  given 
by  English  surgeons,  is  considerably  less  than  that  reported 
by  the  leading  operators  in  the  German,  Austrian,  and  Swiss 
clinics ;  it  is  well  to  bear  in  mind,  however,  that  the  former  are 
conservative,  while  the  latter  are  very  liberal  in  their  selection 
of  cases  suitable  for  radical  operation. 

For  purposes  of  comparison,  it  may  be  stated  that  Cripps, 
of  England,  operated  upon  but  38  cases  out  of  400  patients 
(operability,  9.5  per  cent.).  With  this  selection  of  material  he 
had  an  operative  mortality  of  but  6.5  per  cent.  On  the  other 
hand,  Koenig  operated  upon  96  out  of  120  cases  (operability, 
80  per  cent.),  with  an  operative  mortality  of  32  per  cent. 

Schede  prepared  the  following  table  in  order  to  show  the 
percentage  of  rectal-cancer  patients  radically  operated  upon  at 
several  of  the  larger  European  clinics : — 


564  DISEASES  OF  THE  RECTUM  AND  ANUS 

Table  XXI.     Statistics  of  Opebability  of  Rectal  Cancer 

Czerny    (Heidelberg)    71.1  per  cent. 

Zurich  clinic 50.0         " 

Ziirich  clinic   55.8         " 

Gottingen 78.3 

Marburg 75.4         " 

Breslau 60.6 

Freiburg   (Kraske)    73.0         " 

Rostock    47.2 

Greif swald 48.0 

Bergmann's  clinic    80.0         " 

Bonn  (Schede),  added  by  the  writer 78.7         " 

The  average  percentage  of  operable  cases  at  these  clinics 
is  shown  by  this  table  to  be  65.2  per  cent. 

In  1890  Kronlein  published  elaborate  comparative  statis- 
tics of  the  operability  and  nwrtality  of  the  radical  (Kraske)  op- 
eration for  the  relief  of  rectal  cancer.  This  table  has  since  been 
modified  and  added  to  by  Vogel,  who  has  completed  the  statis- 
tics up  to  February  1,  1901 : — 

Table  XXII.     Vogel's  Modification  of  Kronlein's  Table  on  the 
Operability  and  Mortality  of  Kraske's  Operation 


Operator. 


No.  of  Cases  No.  of  Cases  Operative 

Treated.  Operated  on.  Mortality. 


Konig 120  78.3  per  cent.         32.5  per  cent. 

Czerny   151  71.1  "  10.0 

Kronlein    110  57.2  "  11.1 

Gussenbauer 259  56.0  "  22.7 

Bergmann   155  80.0  "  32.0 

Madelung   Garie 115  46.0  "  19.0 

Kraske 110  78.0  "  18.7 

Kiister   126  75.4  "  25.2 

Hochenegg    141  66.0  "  8.6 

Mikulicz    109  60.6  "  25.7 

Helferich 46  48.0  "  13.6 

Schede    66  80.3  "  32.0 

An  analysis  of  this  table  shows  that  1508  patients  were 
treated  for  rectal  malignancy  by  the  different  operators,  and 
66.4  per  cent,  operated  upon  with  an  average  mortality  of 
20.9  per  cent. 

Out  of  542  sacral  operations  tabulated  by  Prutz,  there 
were  115  deaths:  an  average  mortality  of  21.1  per  cent.  From 
the  percentages  obtained  from  Vogel's  table,  together  with 
those  of  Prutz,  it  is  found  that  the  average  mortaHty  of  the 
large  number  of  cases  represented  is  21  per  cent.     Again,  if 


TREATMENT  OF  MALIGNANT  TUMORS  565 

the  percentages  of  operable  cases  obtained  from  the  tables  of 
Vogel  and  Schede  are  considered  together  it  is  found  that  an 
average  of  65.8  per  cent,  were  considered  operable.  As  a  gen- 
eral rule,  the  greater  the  percentage  of  cases  considered  op- 
erable, the  higher  the  mortahty.  The  mortality  is  sHghtly 
higher  than  it  was  some  years  ago,  but  this  is  easily  explained 
by  the  fact  that  a  larger  number  of  surgeons,  including  many 
inexperienced  in  this  line  of  work,  are  now  performing  the 
radical  operation,  and,  again,  many  cases  are  now  operated 
upon  which  formerly  would  have  been  considered  inoperable. 

Vaginal  Proctectomy. — Owing  to  the  obscurity  of  the  his- 
tory of  vaginal  proctectomy  the  author  has  not  been  able  to 
determine  who  was  the  first  surgeon  to  excise  or  resect  the 
rectum  by  the  vaginal  route.  Certainly  the  operation  was  but 
rarely  mentioned  in  the  literature  prior  to  July,  1890,  when 
Desquins  reported  a  case  wherein  he  had  removed  a  cancer 
involving  the  anterior  rectal  wall  by  splitting  the  recto-vaginal 
septum  and  perineum  and  delivering  the  growth  through  the 
vagina.  The  vaginal  and  perineal  wounds  were  then  united 
with  silver-wire  sutures.  During  the  past  decade,  however, 
vaginal  proctectomy  has  attained  considerable  prominence, 
largely  through  the  contributions  of  Desquins  (1890),  Norton 
(1890),  McArthur  (1891),  Campenom  (1894),  Rhen  (1895), 
Vautrin  (1895),  Price  (1896),  Byford  (1896),  Bristow  (1896), 
Branham  (1896),  Gersuny  and  Sternberg  (1897),  Liermann  and 
Rhen  (1899),  Murphy  (1900),  and  Earl,  who  have  either  im- 
proved the  technic  of  the  operation  or  reported  cases  success- 
fully treated  by  the  procedure.  Several  other  contributions  to 
the  subject  have  been  made  since  Earl  read  his  paper  at  the 
meeting  of  the  Proctologic  Society  in  May,  1900.  Vaginal 
proctectomy  is  sometimes  called  Rhen's  operation,  because  this 
surgeon  was  one  of  the  first  to  describe  the  technic  of  the 
operation  and  call  attention  to  the  good  results  obtained 
from  it. 

Technic  of  Vaginal  Proctectomy. — When  a  malignant  growth 
is  located  within  three  to  five  inches  (7.6  centimeters  to  1.27 
decimeters)  above  the  anus  in  the  female  it  will  be  found  advan- 
tageous to  amputate  or  resect  the  rectum  by  the  vaginal  route, 
since  this  operation  avoids  bony  mutilation  and  destruction  of 
the  pelvic  support.  The  operation  can  be  performed  in  a  com- 
paratively short  time.    The  mortality  following  it  is  very  small. 


566 


DISEASES  OF  THE  RECTUM  AND  ANUS 


The  operation  is  performed  in  three  steps,  as  follows: — 

1.  A  longitudinal  median  incision  of  sufficient  length  is 
made  in  the  posterior  vaginal  wall  and  carried  down  through 
the  perineum.  If  this  does  not  give  sufficient  room,  a  trans- 
verse incision  is  made  just  below  the  cervix  and  the  flaps 
turned  to  either  side. 

2.  An  incision  is  made  encircling  the  anus  half  an  inch 
(1.27  centimeters)  or  more  from  its  margin  (Fig.  181).  The 
rectum  is  then  freed  from  its  attachments,  brought  forward 
through  the  vaginal  incision,  dissected  upward  beyond  the 
growth,  and  the  lower  bowel  amputated  (Fig.  182). 


Fig.  181. — Proctectomy  by  the  Vaginal  Route. 


3.  The  remaining  end  of  the  rectum  is  brought  down  and 
sutured  to  the  skin  around  the  circular  incision,  the  vaginal 
wound  is  closed  with  silk-worm,  wire,  or  catgut  sutures  (Fig. 
183),  and  dressings  applied. 

When  possible,  the  sphincters  should  be  preserved  and  an 
end-to-end  anastomosis  made  in  the  manner  described  in  dis- 
cussing superior  and  inferior  proctectomy.  When  the  disease 
has  destroyed  the  lower  rectum,  the  proximal  end  should  be 
twisted,  as  suggested  by  Gersuny  (Fig.  182),  before  attaching  it 
to  the  skin,  in  order  to  produce  partial  continence  of  feces.  The 
peritoneum  when  injured  may  be  drained  by  means  of  gauze 
placed  behind  the  rectum  or  introduced  through  the  vagina;    or, 


TEEATMENT  OF  MALIGNANT  TUMORS 


567 


if  there  is  little  danger  of  infection,  it  may  be  closed  by  suturing 
it  to  the  bowel. 

The  author  has  performed  vaginal  proctectomy  in  six  se- 
lected cases/  and  has  been  much  pleased  with  the  operation. 
In  his  opinion,  it  should  take  precedence  over  the  operations 
of  Kocher  and  Kraske  in  all  cases  in  which  the  growth  is  so 
situated  that  it  can  be  removed  from  in  front. 

The  advantages  of  vaginal  proctectomy  are  tersely  given 
by  Murphy,  of  Chicago,  as  follows : — 

"1.  The  sacrum  and  posterior  bony  wall  of  the  pelvis  are 
not  disturbed. 


Fig.  1S2. — Proctectomy  by  tlie  Vagina'  Route. 

"2.  The  field  of  operation  is  extensive  and  the  anatomic 
parts  are  accessible  as  in  the  transsacral  operation. 

"3.  The  peritoneal  cavity  is  opened  in  both  the  vaginal  and 
sacral  operations,  and  in  neither  is  it  a  source  of  great  danger. 

"4.  The  diseased  tissue  is  more  accessible  for  inspection,  and 
the  extent  to  which  an  operation  may  be  carried  in  an  upward 
direction  is  as  great,  if  not  greater,  than  by  the  sacral  route. 

"5.  The  peritoneum  may  be  drained  freely  through  the 
vagina. 

"6.  A  perfect  end-to-end  approximation,  either  by  suture 

»  These  operations  were  all  performed  before  January,  1905.  Since  then  he  has  performed 
other  operations  of  the  same  kind. 


568 


DISEASES  OF  THE  RECTUM  AND  ANUS 


or  by  the  use  of  the  button,  may  be  secured.  The  preferable 
method  of  uniting  the  two  ends  is  by  interrupted  sutures  of 
silk;  as  there  is  no  peritoneum  on  the  sphincteric  segment,  the 
danger  of  failure  of  union  with  the  button  is  present. 

"7.  The  sphincter  is  retained  and  the  perineal  body  is  re- 
stored.    There  is  diminished  action  of  the  levator  ani  muscles. 

"8.  When  the  operation  is  complete  the  parts  are  prac- 
tically in  their  normal  positions." 


Fig.  183.— Rectal  Excision  by  the  Vaginal  Route. 


When  feasible,  malignant  neoplasms  located  in  the  upper 
rectum  and  sigmoid  should  be  invariably  removed  through  an 
abdominal  incision  rather  than  by  superior,  inferior,  or  vaginal 
proctectomy;  because  in  this  procedure  less  time  is  required, 
complications  are  fewer,  the  permanent  results  are  just  as  good, 
and  there  is  much  less  danger  of  shock,  hemorrhage,  perito- 
nitis, sloughing  of  the  bowel,  and  fecal  fistula  following  the 


TREATMENT  OF  MALIGNANT  TUMORS  569 

operation.  Again,  if  the  growth  is  removed  through  the  ab- 
domen, there  is  no  mutilation  of  the  ligaments,  muscles,  and 
bones  which  support  the  pelvis;  and  last,  but  not  least,  the 
sphincter-muscle  is  preserved,  and  the  patient  does  not  suffer 
from  fecal  incontinence,  but,  on  the  contrary,  has  perfect  con- 
trol of  his  stools,  which  are  voided  through  the  natural  chan- 
nel instead  of  a  sacral  anus. 

In  those  instances  in  which  the  growth  is  so  low  down 
that  it  cannot  be  drawn  up  into  the  wound  for  resection,  the 
peritoneum  should  be  divided  anteriorly  and  laterally.  When 
necessary,  the  mesorectum  may  be  severed,  but  always  at  a  safe 
distance  from  the  bowel  in  order  to  avoid  injury  to  the  vessels. 

The  proximal  and  distal  ends  of  the  bowel  may  be  approx- 
imated by  means  of  circular  enterorrhaphy  or  the  Murphy  but- 
ton; or  a  lateral  anastomosis  may  be  made  by  using  the  button 
or  a  fine  silk  suture  and  a  straight  needle.  The  abdominal  in- 
cision is  then  closed,  leaving  room  for  a  drain  when  needed. 

When  the  growth  is  so  situated  that  it  cannot  be  dissected 
out  from  above  or  below,  it  should  be  removed  by  laparo- 
proctedomy. 

Laparo-proctectomy  (Celio-proctectomy,  Abdomino-perineal  Ex- 
cision).—  This  term  is  apphed  by  the  author  to  an  operation 
in  which  it  is  necessary  to  attack  the  diseased  rectum  from 
above  through  an  abdominal  incision  and  also  from  below  by 
means  of  superior,  vaginal,  or  inferior  proctectomy,  in  order 
to  free  the  bowel  and  extirpate  the  growth.  Such  an  operation 
is  indicated  when  the  malignant  neoplasm  is  so  situated  in  the 
upper  rectum  and  sigmoid  flexure  as  to  render  impossible  its 
removal  by  either  laparotomy  or  proctectomy  alone. 

Czerny,  in  1883,  was  the  first  surgeon  to  remove  a  cancer 
of  the  rectum  by  this  method.  Quenu  (1895)  and  Reverdin 
(1896)  hold  that,  when  the  rectum  becomes  the  seat  of  maHg- 
nant  disease,  its  function  as  an  organ  is  practically  destroyed. 
When  such  a  procedure  is  necessary,  they  advise  removal  of 
the  rectum  and  all  the  involved  lymph-nodes  by  the  combined 
operation. 

Laparo-proctectomy  is  performed  as  folloivs:  The  abdo- 
men is  opened  by  a  free  incision  in  the  left  inguinal  region, 
about  two  inches  (5.08  centimeters)  to  the  inner  side  of  the 
anterior  superior  spine  of  the  ilium.  The  growth  and  sigmoid 
flexure  are  located,  and  the  latter  lifted  upward  through  the 


570  DISEASES  OF  THE  RECTUM  AND  ANUS 

wound.  The  sigmoid  is  then  divided  between  two  h"gatures, 
at  a  safe  distance  above  the  growth,  the  upper  end  being  held 
by  an  assistant.  The  rectal  end  is  now  freed  by  successively 
ligating  and  dividing  the  mesosigmoid  and  mesorectum  and, 
finally,  by  separating  the  peritoneum  completely  around  the 
bowel.  The  lower  rectum  is  next  detached  from  its  surround- 
ings by  vaginal,  inferior,  or  superior  proctectomy  and  the  dis- 
eased bowel  drawn  up  through  the  pelvis  and  amputated.  The 
proximal  end  of  the  sigmoid  is  sutured  to  the  skin  about  the 
inguinal  incision,  forming  an  artificial  anus;  the  remaining  in- 
cisions are  closed,  provision  being  made  for  free  drainage. 

The  author  has  resorted  to  laparo-proctectomy  for  the  re- 
moval of  a  malignant  disease  of  the  rectum  in  but  few  instances. 
One  of  these  patients,  a  woman  60  years  of  age,  died  from  shock 
a  few  hours  after  the  operation,  which  required  much  time,  owing 
to  adhesions  that  formed  between  the  diseased  bowel  and  sur- 
rounding structures. 

Quenu  has  successfully  operated  in  three  cases  by  the  fol- 
lowing method:  An  artificial  anus  was  established  in  the  left 
iliac  region  some  days  before  excision  of  the  rectum.  The  rec- 
tal end  of  the  bowel  was  isolated  by  inferior  or  sacral  proc- 
tectomy, and  a  hard-rubber  sound,  notched  around  the  end, 
introduced  through  the  lower  colostomy  opening  to  within  one 
inch  (2.54  centimeters)  of  the  superior  limit  of  the  tumor.  The 
bowel  was  then  ligated  around  the  sound,  the  ligature  being 
tightened  in  the  groove  and  the  gut  divided  just  below  this 
point.  The  lower  rectum  was  removed  and  the  sound  with- 
drawn, invaginating  the  upper  end  of  the  bowel  through  the 
artificial  anus.  When  adhesions  of  the  mesorectum  prevent  the 
bowel  being  drawn  upward,  Quenu  forms  a  sacral  anus. 

Proctectomy  by  Invagination.  —  This  operation  consists  in 
making  an  artificial  prolapse  or  invagination  of  the  rectum  by 
drawing  the  latter  down  and  out  through  the  anus,  where  the 
growth  is  excised  or  the  diseased  bowel  resected.  Proctectomy 
by  invagination  is  applicable  to  only  a  small  percentage  of 
cases  of  malignant  tumors  of  the  rectum,  because  most  of  these 
neoplasms  are  located  so  high  up  and  are  so  large  or  so  firmly 
attached  to  the  perirectal  structures  that  it  is  impossible  to  in- 
vaginate  the  growth  through  the  anal  orifice. 

The  operation  is  especially  adapted,  however,  to  the  re- 
moval of  single  or  multiple  cancerous  nodules  occurring  in  the 


TREATMENT  OF  MALIGNANT  TUMORS  571 

rectal  wall  in  the  earlier  stages  of  the  disease,  before  adhesions 
are  formed.  In  such  a  case  the  nodule  is  seized  with  strong 
traction-forceps,  pulled  well  down  below  the  anus,  then  excised 
by  elliptic  incision,  and  the  resulting  wound  immediately  closed 
with  catgut  sutures  or  allowed  to  heal  by  granulation.  This 
operation  is  desirable  in  extirpating  these  nodules,  because  but 
a  narrow  longitudinal  strip  of  the  bowel  is  removed  and  suffi- 
cient mucosa  is  left  to  obviate  the  danger  of  stricture. 

In  a  few  cases  growths  involving  the  entire  circumference 
of  the  bowel  have  been  removed  by  invagination  and  resection 
of  the  diseased  portion,  the  cut  ends  of  the  gut  being  united  by 
end-to-end  anastomosis  with  continuous  or  interrupted  silk 
sutures. 

The  author  has  succeeded  in  but  a  single  case  in  removing 
a  malignant  growth  of  the  rectum  by  the  invagination  method. 
In  this  case,  a  female,  the  growth  was  about  the  size  of  a  small 
lemon  and  situated  in  the  anterior  rectal  wall,  two  inches  (5.08 
centimeters)  above  the  anal  orifice.  It  was  turned  out  through 
the  anus  by  the  middle  and  index  fingers  inserted  into  the  va- 
gina. To  prevent  retraction,  the  bowel  was  grasped  with  for- 
ceps on  either  side  of  the  growth,  and  held  by  an  assistant.  The 
growth  was  then  extirpated  by  making  an  elliptic  incision  and 
the  wound  closed  by  interrupted  catgut  sutures.  There  was  no 
recurrence  at  the  end  of  three  months,  when  the  patient  passed 
from  under  the  writer's  observation. 

In  1899  Steinthal  successfully  operated  three  times  by 
forming  an  artificial  prolapse  of  the  bowel,  including  the 
growth.  Through  the  invaginated  bowel  he  passed  a  colon- 
tube  or  bougie,  and  then  ligated  the  gut  around  the  instrument 
by  means  of  a  strong  elastic  ligature,  placed  well  above  the 
growth,  which  was  left  to  cut  its  way  out.  In  two  of  Steinthal's 
cases  there  was  no  recurrence  of  the  disease  after  two  and  one- 
half  and  four  years,  respectively;  but  in  the  third  case  the 
growth  returned  in  a  short  time,  and  a  second  operation  was 
necessary. 

Maunsell,  of  New  Zealand,  in  1892  successfully  resected 
the  upper  two-thirds  of  the  rectum  and  a  part  of  the  sigmoid 
flexure  by  opening  the  abdomen  and  severing  the  lateral  at- 
tachments of  the  mesorectum,  in  order  to  mobilize  the  bowel. 
The  ends  of  a  piece  of  tape  were  then  introduced  into  the 
lumen  of  the  bowel,  well  above  the  growth,  by  means  of  long 


572  DISEASES  OF  THE  RECTUM  AND  ANUS 

needles  passed  through  the  gut-wall  on  either  side,  and  drawn 
down  through  the  anus  with  forceps.  By  making  traction  on 
the  tape,  the  bowel,  including  the  growth,  was  invaginated 
through  the  anus,  and  the  diseased  portion  excised.  The  ends 
of  the  rectum  were  then  united  and  the  abdominal  wound 
closed  by  means  of  catgut  sutures. 

The  author  wishes  now  to  describe  two  other  operations 
suggested  for  the  relief  of  malignant  disease  of  the  rectum : 
originated,  one  by  Dr.  George  M.  Edebohls,  of  New  York, 
and  the  other  by  Dr.  Howard  Kelly,  of  Baltimore. 

Edebohls's  Operation.  —  Edebohls  holds  that  the  Kraske 
operation  is  never  either  indicated  or  justifiable  in  women. 
Carcinoma  affecting  the  middle  or  lower  third  of  the  rectum 
can  be  extirpated  per  vaginam,  by  perineotomy,  or  by  means  of 
an  incision  between  the  coccyx  and  anus,  without  the  necessity 
of  bone-resection.  Cancer  of  the  upper  end  of  the  rectum  or 
of  the  sigmoid  can  be  removed  through  an  anterior  abdominal 
incision,  sacrificing  the  uterus  if  it  be  in  the  way,  as  well  as  by 
a  Kraske  operation.  For  this  purpose  Edebohls  has  planned 
and  executed  an  operation  the  essentials  of  which  consist  in 
abdominal  hysterectomy,  resection  of  the  carcinomatous  bowel,  and 
end-to-end  anastomosis  of  the  sigmoid  and  rectum,  all  performed  at 
one  time. 

Briefly  described,  the  following  are  the  principal  advan- 
tages claimed  for  this  operation : — 

1.  Approach  to  the  bowel  is  easy  and  the  resection  can  be 
made  in  situ. 

2.  Glands  lying  above  the  third  sacral  foramina  can  be 
easily  removed  from  in  front. 

3.  The  liver  can  be  inspected,  and,  if  metastases  have 
formed,  colostomy  can  be  substituted  for  resection. 

4.  The  bowels  can  be  moved  immediately  without  soiling 
the  field  of  operation. 

5.  Convalescence  is  more  rapid  and  agreeable,  because  the 
patient  can  assume  any  position. 

Edebohls  has  had  but  one  opportunity  to  perform  his  op- 
eration:  on  February  26,  1901,  he  removed  a  carcinoma,  in- 
volving the  recto-sigmoidal  junction,  from  a  Avoman  four 
months  pregnant,  first  removing  the  gravid  uterus  and  then 
resecting  the  diseased  bowel.  Convalescence  was  uneventful, 
and  the  patient  was  out  of  bed  on  the  sixteenth  day. 


TREATMENT  OF  MALIGNANT  TUMORS  573 

Colo-proctostomy.  —  This  signifies  the  implantation  of  the 
end  of  the  colon  into  the  rectum.     The  operation  was  first 
performed  by  Kelly,  of  Baltimore,  in  order  to  avoid  making  an 
artificial  anus.    It  is  applicable  only  when  the  growth  is  situated 
in  the  upper  rectum  or  sigmoid  colon,  and  is  performed  after 
the  following  manner:    The  sphincter-muscle  is  divided,  and, 
with  the  patient  in  the  Trendelenburg  position,  a  median  ab- 
dominal incision  is   made  of  sufficient  length  to  expose  the 
pelvic  contents.     The  growth  is  then  removed  and  the  rectal 
end  of  the  gut  sutured.     If  it  is  impossible  to  remove  the 
growth,  the  bowel  is  divided  above  it  and  the  distal  end  closed 
accurately.     Strong  silk  sutures,  several  inches  in  length,  are 
now  passed  through  the  entire  thickness  of  the  proximal  end 
of  the  colon.     Long-handled  forceps  are  passed  up  the  rectum, 
and  the  anterior  wall  of  the  rectum  is  made  to  bulge  out  just 
below  the  growth,  or,  if  the  latter  has  been  extirpated,  two  or 
three  inches  (5.08  to  7.6  centimeters)  below  the  closed  end  of 
the  bowel;    at  this  point  the  rectum  is  incised  and  the  long 
sutures  are  grasped  by  the  forceps  and  puhed  down  and  out 
through  the  anus,  thus  telescoping  the  proximal  end  of  the  colon 
into  the  rectum  the  desired   distance.     This   procedure   also 
causes  the  peritoneal  surface  of  the  rectum  to  turn  inward, 
bringing  it  in  contact  with  the  serosa  of  the  sigmoid,  and  in- 
suring union  of  these  surfaces.     If  thought  best  further  to 
guard  against  fecal  extravasation,  the  rectum  can  be  sutured 
to  the  colon.    The  sutures  hanging  out  of  the  anus  are  drawn 
sufficiently  taut  to  prevent  the  upper  end  of  the  bowel  from 
escaping  from  the  rectum  in  case  of  vomiting,  and  are  held  in 
place  by  strong  forceps  until  union  is  assured.    The  abdominal 
wound  is  closed  immediately,  leaving  room  for  a  drain,  if  neces- 
sary, until  all  danger  of  fecal  extravasation  is  past. 

COMPLICATIONS   AND   SEQUELS 

The  most  frequent  complications  and  sequels  encountered 
during  or  following  extirpation  of  all  or  a  part  of  the  rectum 
for  malignant  disease  are:  Injury  to  adjacent  organs,  nerves, 
or  spinal  canal ;  uremia,  hemorrhage,  pain,  infection,  and  fecal 
fistulse ;  stricture  ;  incontinence  of  feces ;  gangrene  of  the  peri- 
toneum, bowel,  or  skin-flap  and  attached  bone;  pelvic  de- 
formity, necrosis  of  the  sacrum,  and  procidentia  of  the  rectum 
or  uterus. 


574  DISEASES  OF  THE  RECTUM  AND  ANUS 

When  the  growth  is  adherent  to  adjacent  organs,  it  not 
infrequently  happens  that  the  ureter,  bladder,  urethra,  seminal 
vesicles,  prostate,  or  vagina  are  injured.  If  such  a  wound  is 
promptly  repaired,  no  serious  trouble  will  ensue,  but,  when  it 
is  ignored  or  overlooked,  serious  complications  may  arise,  such 
as  the  formation  of  a  fistula,  through  which  the  urine  and  some- 
times the  feces  are  discharged. 

Temporary  Vesical  Disturbances,  such  as  pain  in  the  bladder 
and  difficult  micturition,  are  nearly  always  troublesome  symp- 
toms for  the  first  few  days  after  the  operation,  and  are  due  to 
reflex  manifestations,  shock,  and  pressure  exerted  upon  the 
urethra  by  the  dressings.     Uremia  is  not  uncommon. 

Primary  Hemorrhage  is  rarely  alarming,  and  secondary 
bleeding  seldom  occurs.  The  author  has  had  but  one  case  of 
secondary  hemorrhage  following  extirpation  of  the  rectum. 
This  patient  was  a  man,  and  the  bleeding  occurred  on  the  fifth 
day  after  a  difhcult  stool;  the  wound  was  promptly  reopened, 
and  the  spurting  vessel  located  and  tied.  No  further  trouble 
from  this  source  occurred. 

The  post-operative  Pain  of  amputation  and  resection  of 
the  rectum  is  not  very  severe,  and  gradually  diminishes  after 
the  third  day.  From  this  time  on  suffering  is  most  intense 
during  and  immediately  following  defecation,  especially  when 
a  fistula  is  formed  and  the  wound  is  deluged  with  feces.  These 
sufferers  not  infrequently  complain  of  soreness  over  the  end 
of  the  sacrum  and  of  reflected  pain  in  the  bladder  and  down 
the  limbs  for  several  weeks  or  months  after  the  operation. 

Infection  is  the  compHcation  most  to  be  dreaded  during  the 
first  few  days  after  proctectomy.  Because  of  the  nature  of  the 
operation  and  the  function  of  the  bowel,  infection  is,  unfortu- 
nately, quite  common.  The  suppurative  process  may  be  con- 
fined to  the  skin-wound,  suture-line  in  the  gut  or  peritoneum, 
or  it  may  involve  the  entire  field  of  operation,  causing  a  pro- 
longed convalescence  and  an  unsatisfactory  result,  or  even 
death  from  peritonitis  or  exhaustion.  The  most  frequent  se- 
quel of  infection  is  posterior  fecal  fistula,  due  to  separation  of 
the  suture-line  in  the  bowel ;  such  a  fistula  can  usually  be  closed 
by  cauterization  or  plastic  operation. 

Stricture  following  the  extirpation  of  a  part  of  the  rectum 
is  frequently  to  be  anticipated.  If  the  gut  has  been  resected, 
the  constriction  is  caused  by  a  circular  scar  at  the  point  of 


TREATMENT  OF  MALIGNANT  TUMORS  575 

anastomosis,  but,  when  the  diseased  bowel  has  been  amputated 
and  the  proximal  end  sutured  to  the  anus,  it  frequently  retracts, 
and  a  partial  or  complete  cicatricial  stricture  is  formed  at  or 
just  above  the  anus. 

Incontinence  of  Feces.  —  One  of  the  most  deplorable  se- 
quels of  rectal  excision  is  fecal  incontinence.  Patients  are  not 
always  left  in  this  unfortunate  condition  when  the  external 
sphincter  remains  intact,  but  when  the  muscle  is  destroyed  the 
surgeon  is  fortunate  indeed  if  his  patient  has  complete  conti- 
nence. There  are  two  degrees  of  incontinence,  viz. :  partial  and 
complete.  When  the  solid  feces  are  retained,  the  condition  is 
designated  partial;  and  where  there  is  no  control  over  either 
gas,  liquid,  or  solid  feces,  it  is  known  as  complete  incontinence. 
One  consolation  to  the  surgeon  in  these  cases  is  the  knowl- 
edge that,  if  the  operation  had  not  been  performed,  the  disease 
eventually  would  have  caused  incontinence. 

In  order  to  diminish  the  danger  of  incontinence  after  ex- 
tirpation of  the  growth,  the  methods  of  Willems,  Gersuny,  and 
Hochenegg,  described  elsewhere,  should  be  tried,  when  fea- 
sible. The  following  table,  giving  the  functional  results  of  his 
operations,  was  prepared  by  Hochenegg,  to  show  the  advan- 
tages of  his  "pull-through"  method  over  those  of  resection : — 

Table  XXIII.     Statistics  of  Incontinence  Following  Pkoctectomy 

Result.  Pull-Through  Method.  Resection. 

Complete  continence 47         1-17  36        4-11 

Partial  continence 29         7-17  27         3-11 

Incontinence    23         9-17  36        4-11 

Other  complications  occur  so  rarely  and  cause  so  little 
annoyance  that  they  need  not  be  discussed  at  length. 

PERMANENT   RESULTS 

The  permanent  results  following  extirpation  of  malignant 
growths  of  the  rectum  depend  largely  upon  the  care  observed 
in  selecting  cases  and  also  upon  the  thoroughness  of  the  opera- 
tion. When  the  neoplasm  involves  neighboring  or  distant  or- 
gans and  every  vestige  of  the  growth  is  not  removed,  no  lasting 
benefits  are  derived  from  the  operation.  On  the  other  hand, 
if  the  disease  is  confined  to  the  rectum  and  its  extirpation  is 
complete,  the  life  of  the  patient  is  lengthened,  and  not  infre- 
quently a  cure  is  effected  by  the  operation.     Unfortunately,  it 


576  DISEASES  OF  THE  RECTUM  AND  ANUS 

is  impossible  in  many  cases  to  determine,  before  operation,  the 
extent  of  the  growth  and  whether  its  complete  removal  can  be 
accomplished. 

In  unfavorable  cases  recurrence  may  take  place  at  the  site 
of  the  original  growth,  or  metastases  may  form  in  distant  or- 
gans, such  as  the  liver,  lungs,  etc.  This  may  occur  in  a  few 
weeks  or  months  after  the  operation  or  not  until  after  some 
years  have  elapsed.  It  is  customary,  however,  to  classify  as 
cured  all  patients  who  survive  the  operation  for  three  or  more 
years  without  signs  of  a  return  of  the  disease. 

The  percentage  of  cures  following  the  operations  of  resec- 
tion or  amputation  of  the  rectum  for  the  relief  of  malignant 
disease  is  about  16  per  cent. 

Of  the  cases  operated  upon  by  Schede,  thirty-six  survived 
the  operation,  and  six  (16.7  per  cent.)  of  these  were  alive  and 
well  after  three  years.  Kronlein  holds  that  four-fifths  of  these 
patients  recover  from  the  operation  and  that  one-seventh  of 
this  number  are  cured.  The  following  table,  compiled  by  him, 
giving  the  permanent  results  obtained  by  leading  operators, 
shows  that  his  estimate  is  not  far  from  right,  as  the  average 
percentage  is  approximately  15.6  per  cent. 

Table  XXIV.     Permanent  Results  Obtained  fkom  Rectal  Excision 
BY   Leading   Operators   of   Europe 

Operator.  Permanent  Results. 

Kocher    28.5  per  cent. 

Von  Bergmann 17.4        " 

Kuster    16.8 

Kronlein     16.0 

Czerny 14.6         " 

Kraske    13.7         " 

Hochenegg 12.9         " 

Madelung 11.3 

Mikulicz  9.7 

If  Schede's  results  (16.7  per  cent.)  are  added  to  the  per- 
centage obtained  from  Kronlein's  table,  the  average  is  found 
to  be  16  per  cent. 

From  the  above  statistics  it  is  evident  that,  in  round  num- 
bers, 16  per  cent,  of  rectal-cancer  patients  permanently  recover 
after  radical  operation.  This  unquestionably  demonstrates  the 
advisability  of  rectal  resection  and  amputation  for  the  relief  of 
rectal  malignancy  in  suitable  cases. 


TREATMENT  OF  MALIGNANT  TUMORS  577 

CAUSES   OF   DEATH 

The  following  are  the  most  common  causes  of  death  from 
rectal  resection  and  amputation:  Shock,  septic  peritonitis, 
suppression  of  urine,  exhaustion,  extensive  suppuration,  hem- 
orrhage, empyema;  gangrene  of  the  peritoneum,  gut,  or  osteo- 
integumentary  flap;    atheromatous   disease,   and  pyelonephritis. 

The  treatment  of  sarcoma  is  pre-eminently  surgical,  and 
requires  practically  the  same  methods,  palliative  and  radical,  as 
those  described  for  the  relief  of  carcinoma.  All  palliative  and 
non-operative  measures  are  contra-indicated  except  in  inoperable 
cases.  As  before  stated,  better  results  are  to  be  had  from  the 
use  of  drugs  and  toxins  in  the  treatment  of  sarcoma  than  in 
the  treatment  of  cancer.  While  cures  are  very  rarely  efTected 
by  the  use  of  these  agents,  a  number  of  cases  have  been  re- 
ported in  which  the  tumor  was  reduced  in  size  or  its  growth 
temporarily  checked  and  the  patient's  suffering  partially  re- 
lieved for  the  time  being.  In  most  cases,  however,  death 
eventually  followed  from  local  or  general  dissemination. 


LITERATURE   ON  MALIGNANT  TUMORS   OF  THE   RECTUM  AND   ANUS 


Allingham  (H.  W.) :  "Colotomy:  Inguinal,  Lumbar,  and  Transverse,"  etc.,  1892, 
Allingham    (William  and  H.  W.)  :    "Cancer  of  Rectum,"  Diseases  of  Rectum 

and  Anus,"  pp.  284-339,  1888. 
Arnd:    "Beitrilge  zur  Statistik  der  Rectumcarcinome,"  Deutsche  Zeit.  f.  Chir., 

Bd.  xxxii,  1891. 
Ball:    "Sarcomata  of  the  Rectum,"  "Diseases  of  Rectum  and  Anus,"  pp.  317, 

325,  1887. 
Bardenheuer:     "Die    Resection    des    Mastdarmes,"    Volkmann's    Samml.    Tdln. 

Vortnige,  No.  298,  1887. 
Belin:    "De  I'anus  iliaque  dans  la  cure  radicale  du  cancer  du  rectum,"  Progrds 

Bled.,  No.  40,  1897. 
Bergmann   (by  Wollf)  :    "Radical  Operation  for  Rectal  Cancer,"  Archiv  f.  klin. 

Chir.,  Ixii,  1900. 
Bloch:    "On  operationer  par  Cancer  Recti,"  Hospitals-tidende,  No.  1,  1890. 
Boas:    "Sarcoma,"  etc.,  "Diseases  of  Intestines,"  pp.  329-31,  1901. 
Borelius:    "Modification  of  Kraske's  Operation,"  CentralM.  f.  Chir.,  1893. 
Branham:    "Excision  of  Rectum,"  Trans.  Amer.  Assoc.  Obstet.  and  Gynec,  ix, 

p.  439,  1896. 
Briddon:    "Cancer  of  Rectum,  Extirpation,"  etc.,  iV.  Y.  Med.  Gaz.,  ix,  p.  113, 

1882. 
Bryant   (J.  D.) :    "Colostomy,"  "Operative  Surgery,"  ii,  pp.  675-702,  1901, 

37 


578  DISEASES  OF  THE  RECTUM  AND  ANUS 

Bryant  (Thomas) :  "Treatment  of  Rectal  Cancer,"  "Practice  of  Surgery,"  p. 
582,  1885. 

Butlin:  "Rectal  Cancer,"  "Operative  Surgery  of  Malig.  Disease,"  second  edi- 
tion, p.  275,  1900. 

Cadol:  "Resume  of  Various  Methods  of  Treating  Cancer  of  the  Rectum," 
Archives  Gen.  de  Med.,  i,  p.  582,  1898. 

Chassaignac:  "Cancer  du  Rectum  opere  par  ecrasement  linear,"  etc.,  Gaz.  des 
Hop.,  Paris,  xxx,  p.  30,  1857. 

Coley:  "Cancer,  Symptomatology  and  Treatment,"  "Twentieth  Century  Prac- 
tice of  Medicine,"  xvii,  1898. 

Cooper  and  Edwards:  "Cancer  of  the  Rectum,"  "Diseases  of  Rectum  and 
Anus,"  p.  184,  1892. 

Cripps:  "Cancer  of  Rectum:  Pathology,  Diagnosis,  and  Treatment,"  etc. 
London,  1890. 

Czerny:  "Casuistische  Mittheilungen  aus  der  chirurg.  Klinik  zu  Heidelberg," 
Milnchener  med.  WocJi.,  No.  11,  1896. 

Dennis:  "Malignant  Neoplasms  of  the  Rectum,"  "System  of  Surgery,"  iv,  p. 
480,  1896. 

Depage:  "Resultats  eloignes  de  la  resection  du  rectum  pour  cancer,"  Jour. 
Med.  de  Bruxelles,  No.  1,  1898. 

Edebohls:    "The  Kraske  Operation  in  Women,"  Amer.  Jour.  Obstet.,  xliv.  No. 

2,  p.  162,  1901. 

Edwards:     "The  Removal  of  High-Lying  Cancer  of  the  Rectum  by  Kraske's 

Method,"  Brit.  Med.  Jour.,  May  15,  1897. 
Faget:    "Excision  of  the  Rectum,"  1739. 
Finet:     "De  la  valeur  curative   et  palliative   de   I'exerese   dans   le   cancer   du 

rectum,"  These  de  Paris,  1896. 
Gerster:    "Adenocarcinoma  of  the  Rectum,"  N.  Y.  Med.  Jour.,  xli,  p.  255,  1885. 
Gersuny:     "Ein   dauernd   geheilter   Fall   von   Carcinoma   Recti,"   Wiener  med. 

Woch.,  xxviii,  pp.  710-12,  1878. 
Hartmann:    "Rectal  Cancer,  Colostomy  foi',"  Revue  de  Chir.,  Paris,  Nov.   10, 

1900. 
Hauser:    "Krebs  des  Mastdarms  und  der  Scheide,"  Oesterr.  med.  Woch.,  Wien, 

pp.  57-62,  1844. 
Heimann:    "Carcinoma  of  the  Digestive  Tract,"  etc.,  ArcMv  f.  Id  in.  Chir.,  xlvi, 

p.  31,  1899. 
Heinecke:     "Ein   Vorschlag   zur  Extirpation   hochgelegener  Rectumcarcinom," 

Milnchener  med.  Woch.,  xxxv,  37,  1888. 
Hemmeter:    "Carcinoma,"  "Diseases  of  the  Intestines,"  i,  p.  678,  1901. 
Hildebrand :     "Zur   Statistik   der   Rectumcarcinome,"   Deutsche  Zelt.   f.    Chir.y 

xxvii,  329,  1887-88. 
Hochenegg:      "Meine    Operationserfolge    bei    Rectumcarcinom,"    Wiener    klin. 

Woch.,  May  3,  1900. 

"Operative  Results  of  Rectal  Carcinoma,"  Wiener  1:1  in.  Woch.,  May 

3,  1900. 

(By  Lorenz.)     "Radical  Operation  in  Rectal  Cancer,"  etc.,  Archlv  f. 
klin.  Chir.,  Ixiii,  p.  854,  1901. 
Iversen:    "Bericht  iiber  247  Fiille  von  Operationen  beim  Cancer  Recti."    Kopen- 
havn,  1890. 


TREATMENT  OF  MALIGNANT  TUMORS  579 

Jaboulay:    "De  traitement  de  cancer  du  rectum,"  Province  Med.,  No.  1,  1896. 
Jaennel:    "Cancer  of  the  Rectum,  Abdominal-Perineal  Extirpation  of,"  Archives 

Prov.  de  CMr.,  Paris,  June,  1901. 
Kammerer:    "Excision  of  the  Rectum,"  N.  Y.  Med.  Record,  xlvi,  p.  97,  1894. 
Kelsey:     "Rectal  Cancer,"   "Diseases  of  the  Rectum  and  Anus,"  pp.   369-404, 

1890. 

"Surgical  Treatment  of  Rectal  Cancer,"  Amer.  Jour.  Med.  Sciences, 

Ixxx,  p.  377,  1880. 
Konig:     "Ueber    die    Prognose    der    Carcinome    naeh    chirurgisclien    Eingriffen 

mit   besonderer   Beriicksichtigung   des    Carcinoma   Recti,"    VerJiandl.    d. 

Deutschen  G-esellschaft  f.  CMr.,  Berlin,  xvii,  Pt.  II,  pp.  25-36,  1888. 
Kraske:    "Excision  of  the  Rectum,"  etc.,  Archiv  f.  klin.  Clilr.,  Bd.  xxxiii,  p. 

566,  1886. 

"Erfahrungen  iiber  den  Mastdarmkrebs,"   Yolkmann's  Samml.  klin. 

Yortrdge,  183  and  184,  1897. 

"Zur    Exstirpation    hochsitzender    Mastdarmkrebse,"    Terhandl.    d. 

Deutschen  Gesellschaft  f.  CMr.,  1900. 
Kronlein:    'Statistics  of  Rectal  Cancer,"  Terhandl.  d.  Deutschen  Gesellschaft 

f.  CMr.,  1900. 
Kuster  (by  Wendel) :    "Statistics  of  Rectal  Carcinoma,"  Deutsche  Zeit.  f.  CMr., 

i,  p.  289,  1872. 
Levy:    "Ueber  Resection  des  Mastdarms,"  Berliner  klin.  Woch.,  May  7,  1900. 
Liermann:     "Zur  vaginalen  Methode  bei  Mastdarmoperationen,"   CentralM.  f. 

CMr.,  No.  13,  1898. 
Lisfranc:     "Observation   sur   une   affection   cancereuse   du   rectum   guerie   par 

I'excision,"  Revue  Med.  de  Franc,  et  Etrang.,  Paris,  ii,  380-384,   1826. 

Also  Gaz.  des  Hop.,  Paris,  ix,  p.  621,  1835. 
Lobstein:     "Ueber   die   Methoden    der   Mastdarmexstirpation,"    Berliner   klin. 

Woch.,  Nos.  31  and  32,  1897. 
Madelung:  "Eine  Modification  der  Colotomie  wegen  Carcinoma  recti,"  Terhandl. 

d.  Deutschen  Gesellschaft  f.  CMr.,  xiii,  pp.  118-121,  1884. 
Magill :    "Carcinoma  Causing  Intussusception,"  Annals  of  Surgery,  xx,  p.  651, 

1894. 
Maisonneuve:    "Cancroide  Volumineux  du  Rectum,"  etc.,  Gaz.  des  Hop.,  Paris, 

xxxiii,  p.  450,  1860. 
Mann :    "Excision  of  the  Rectum,  New  Operation  for,"  Jour.  Amer.  Med.  Assoc, 

xxxvii,  p.  23,  1901. 
Mathews:    "Cancer  of  the  Rectum,"  "Diseases  of  the  Rectum  and  Anus,"  pp. 

366-426,  1896. 
Maydl:     "Carcinoma   Recti:    Colotomia,"   etc.,   Wiener  med.   Presse,  xxiv,   pp. 

500-3,  1883. 
Maylard:     "Pathology   of   Carcinoma   of   the   Rectum,"   "Surgery   of  the   Ali- 
mentary Canal,"  pp.  613-19,  1896. 
McCosh:    "Excision  of  the  Rectum  for  Cancer,"  2V.  Y.  Med.  J  our.,  Ivi,  p.  253, 

1892. 
Moulonguet:    "Sur  un  procede  nouveau  du  resection  du  rectum,"  Bull,  et  Mem. 

de  la  Soc.  de  CMr.,  xx,  p.  646,  1894. 
Murphy:    "Resection  of  the  Rectum  per  Vaginam,"  Trans.  Southern  Surg,  and 

G-ijnec.  Soc,  xxiii,  p.  334,  1900. 


580  DISEASES  OF  THE  RECTUM  AND  ANUS 

Nepveu:    "Rectal  Melanosis,"  Mem.  des.  Chir.,  Paris,  1880. 

"Traitement  du  cancer  ano-rectal,"  Gaz.  Hebd.  d.  Med.,  Paris,  xviii, 

p.  460,  1881. 
Paget:    "Inheritance  of  Cancer,"  Trans.  Path.  8oc.  London,  xxv,  p.  317,  1874. 
Paul:    "Colectomy  for  Rectal  Cancer,"  Brit.  Med.  Jour.,  i,  p.   1139,  1895. 

"Colloid  Cancer  of  the  Rectum,"  Liverpool  Med.-Chir.  Jour.,  i,  p. 

207,  1881. 
Pichler-Prutz :    "Zur  Statistik  der  sacral  operirten  (Kraske)  Rectumcarcinome," 

ArcJiiv  f.  klin.  Chir.,  Ixiii,  p.  237,  1901. 
Polonson:     "Nouvelle    Methode    operatoire    pour    la    resection    de    cancer    du 

rectum,"  Lyon  Med.,  xlvi,  pp.  67-75,  1884. 
Prutz:    "Statistics  of  Rectal  Excision,"  Archiv  f.  klin.  Chir.,  Ixii,  ICOO. 
Quenu:     "Extirpation    Abdomino-perineale    de    cancer    du    rectum,"    Bull,    et 

Mem.  Soc.  de  Chir.  de  Paris,"  xxvii,  p.  185,  1901. 

"Amputation  of  Cancerous  Rectum,"  Mem.  Soc.  de  Chir.,  p.  163,  1897. 

"Carcinoma  of  the  Rectum,"  "Chir.  du  Rectura,"  i,  1889. 

"Du  choix  des  procedes  operatoires  dans  I'extirpation  des  cancers 

du  rectum,"  Bull,  et  Mem.  de  la  Soc.  de  Chir.,  xxiii,  p.  488,  1897. 

"Technique    operatoire    pour    I'amputation    du    rectum    cancereux," 

ibidem,  p.  163. 
Quenu  et  Laudel:    "Histologic  pathologique  des  cancer  du  rectum,"  Revue  de 

Chir.,  No.  11,  1897;   No.  1,  1898. 
Reclus:    "Traitement  du  cancer  anorectal,"  Gaz.  Hebd.  d.  Med.,  Paris,  xviii, 

p.  426,  1881. 
Rhen:    "Modification  von  Kraske's  Operation,"  Deutsche  Kong.  f.  Chir.,  1890. 
(By  Liebman.)     "Vaginal  Rectal  Excision  of  the  Rectum,"  Bruns's 

Beitrdge  s.  klin.  Chir.,  xxv,  p.  89,  1899. 
Rose :    "Early  Colotomy  in  the  Treatment  of  Malignant  Disease  of  the  Rectum," 

Practitioner,  July,  1897. 
Routier:    "Cancer  du  rectum:    Resection  par  la  voie  sacree,"  Revue  de  Chir., 

1889. 
Roux:    "Excision  d'un  cancer  du  rectum,"  etc..  Rev.  Med.  de  la  Suisse,  1887. 
Rydygier:    "Kraske's  Operation,"  Centralbl.  f.  Chir.,  1893. 
Schede:    "Results  of  Radical  Operation  for  Carcinoma  of  the  Rectum,"  Deutsche 

Zeit.  f.  Chir.,  lix,  1901. 

"Zur  Operation  des  Mastdarmkrebses,"   etc.,   Deutsche  med.   Woch., 

xiii,  p.  1048,  1887. 
Schmidt:     "Ueber    die    Operationsmethoden    bei    Rectumcarcinom    und    deren 

Enderfolge,"  Berliner  klin.  Woch.,  No.  24,  1892. 
Schneider:     "Treatment   of   Cancer   of   the   Rectum,"   Beitrdge  z.   klin.   Chir., 

xxvi,  1900. 
Senn:    "Pathology  of  Carcinoma  of  the  Rectum,"  "Pathology  and  Treatment 

of  Tumors,"  p.  336,  1895. 
Sonnenburg:     "Die    Colotomie   in    der    Behandlung    der   Mastdarmcarcinome," 

Berliner  klin.  Woch.,  xxiii,  pp.  841-43,  1886. 
Steinthal:     "Proctectomy   by   Invagination,"   Bruns's  Beitrdge  z.   klin.   Chir., 

xxvi,  p.  835,  1899. 
Stengel:    "Pathology  of  Intestinal  Carcinoma,"  "Text-book  of  Pathology,"  pp. 

5-18,  1899. 


TREATMENT  OF  MALIGNANT  TUMORS  531 

Sternberg:     "Ueber  den   Rectovaginalschnitt  bei   Mastdarmoperationen,"   Cen- 

tralbl.  f.  CUr.,  No.  11,  1897. 
Stierlin:     "Ueber  die   operative  Behandlung  des  Reetumcarcinoms   und  deren 

Erfolge,"  Beitrdge  z.  klin.  CUr.,  p.  609,  1899. 
Stimson:    "Contribution  to  the  Study  of  Rectal  Cancer,"  Arch.  Med.,  Aug.,  1879. 
Thoma:    "Pathology  of  Carcinoma,"  "Text-book  of  General  Pathology,"  p.  592, 

1896. 
Trelat:     "Epithelioma  du  Rectum:     Colotomie  lombaire,"   Gaz.  des  Hop.,  No. 

126,  1887. 
Tuttle:    "Cancer  of  the  Rectum,"  Jour.  Amer.  Med.  Assoc.,  xxviii,  p.  579,  1897. 
Van  Buren:    "Rectal  Cancer,"  "Diseases  of  the  Rectum,"  pp.  322-62,  1882. 
Vogel:    "Cancer  of  the  Rectum:    Statistics  and  Treatment,"  Deutsche  Zeit.  f. 

CUr.,  1901. 
WagstaflFe:    "Ossifying  Cancer  of  the  Rectum,"  Trans.  Path.  Sac.  London,  xx, 

p.  176,  1869. 
Walker:    "Modification  of  Kraske's  Operation,"  Mathews's  Med.  Quart.,  i,  p. 

542,  1894. 
Weir:    "Formation  of  an  Artificial  Anus  for  Rectal  Cancer,"  N.  T.  Med.  Record, 

Ivii,  p.  661,  1900. 

"High-Seated   Rectal    Cancer:     New    Operation,"    etc..   Jour.    Amer. 

Med.  Assoc,  xxx,  p.  13,  1901. 
Weljaminow:    "Ueber  die  Exstirpation  des  Mastdarmes  mit  vorausgeschickter 

Oder   gleichzeitiger   Kolotomie   naeh    Schinzinger-Madelung,"    Chirurget- 

schenski  Westnik.,  Jan.-May,  1889. 
Williams:    "Statistics  of  Rectal  Cancer,"  Lancet,  London,  May  24,  1884. 

"Cancer,"  "Twentieth  Century  Practice  of  Medicine,"  xvii,  1898. 
Williams,  F.  H.:    "Treatment  of  Cancer  by  X-rays,"  pp.  440-445,  1901. 
Wolflf:     "Ueber   die   Radicaloperation   des   Mastdarmkrebses,"   ArcMv   f.   klin. 

Chir.,  Ixii,  p.  232,  1900. 
Ziegler:     "Carcinoma    of   the    Intestines,"    "Text-book    of    Special    Pathologic 

Anatomy,"  pp.  678-80,  1898. 
Ziemssen:    "Rectal  Cancer,"  etc.,  Deutsche  Arch.  f.  klin.  Med.,  Ivi,  1895-96. 
Zupper:    Wien.  klin.  Woch.,  1901. 


CHAPTER  XXXIV 

COLOSTOMY   (COLOTOMY,  ARTIFICIAL  ANUS) 

Colostomy  is  an  operation  wherein  any  part  of  the  colon 
is  brought  out,  sutured  to  the  skin,  and  opened,  with  the  object 
of  diverting  the  fecal  current  and  preventing  its  passage  over 
the  diseased  bowel  below  the  opening  formed.  The  term 
colotomy  has  been  frequently  applied  to  this  procedure,  but 
improperly  so,  because  colotomy  consists  in  opening  the  colon 
for  any  purpose  (removal  of  foreign  bodies,  etc.) ;  the  incision 
in  the  bowel  is  then  closed,  the  colon  returned  to  the  abdomen, 
and  the  external  wound  immediately  sutured. 

Littre,  in  1710,  first  suggested  establishing  an  artificial 
anus  in  the  inguinal  region  (inguinal  or  iliac  colostomy,  Littre's 
operation)  for  the  relief  of  children  suffering  from  congenital 
malformations  of  the  rectum  and  anus;  but  more  than  half  a 
century  elapsed  before  the  operation  was  performed  on  the 
living. 

In  1776  Pilore  made  an  artificial  anus  in  the  cecum  to 
relieve  a  patient  suffering  from  obstruction  due  to  a  malignant 
tumor.  Duboise,  however,  in  1783,  appears  to  have  been  the 
first  surgeon  to  perform  the  operation  for  a  congenital  defect 
in  the  ano-rectal  region. 

Callisen  described,  in  1770,  an  operation  whereby  the 
colon  could  be  reached  and  opened  without  injury  to  the  peri- 
toneum, by  means  of  an  incision  made  in  the  lumbar  region 
(lumbar  colostomy).  This  operation  was  regarded  with  dis- 
favor until  modified  and  enthusiastically  championed  by 
Amussat  in  a  series  of  papers  published  during  the  years  from 
1835  to  1843.  Since  the  publication  of  these  articles  the  op- 
eration has  been  known  as  "Amussat's  operation."  The  author, 
however,  would  suggest  that  the  procedure  be  designated  as 
the  ''Callisen-Amussat  operation,"  thus  honoring  both  sur- 
geons :  Callisen,  who  devised  the  operation,  and  Amussat, 
through  whose  efforts  it  was  improved  and  popularized. 

The  establishment  of  an  artificial  anus  in  any  part  of  the 
colon  was  formerly  looked  upon  with  very  great  disfavor,  and 
(582) 


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COLOSTOMY  583 

this  prejudice  against  the  operation  has  not  been  entirely  over- 
come at  the  present  time.  Formerly  the  high  mortality;  the 
limited  benefit  derived  from  the  operation,  which  was  resorted 
to  only  in  cancer  cases ;  the  great  annoyance  caused  the  patient 
by  discharge  of  feces  through  an  imperfect  anus  in  an  un- 
natural location,  and  the  fact  that  the  artificial  opening  was 
made  permanent  were  just  reasons  for  advising  against  this 
procedure. 

The  prejudice  toward  colostomy,  while  not  as  great  as 
formerly,  is  yet  sufficient  to  deter  a  large  class  of  patients  from 
seeking  aid  through  the  operation,  who  could  be  relieved,  if 
not  entirely  cured,  of  their  suffering,  by  the  formation  of  an 
artificial  anus.  This  unfortunate  state  of  affairs  is  due  largely 
to  the  ignorance  of  both  physicians  and  the  laity  as  regards  the 
improved  technic  and  the  merits  of  the  operation  and  its  in- 
creased field  of  usefulness.  Some  years  ago  an  artificial  anus 
was  made  as  a  palliative  measure  only  in  incurable  diseases ; 
at  the  present  day,  however,  the  manifold  beneficent  results  of 
the  procedure  are  recognized,  and  colostomy  is  employd  both 
as  a  curative  and  a  palliative  procedure  for  the  relief  of  a  variety 
of  diseases  which  otherwise  would  be  considered  incurable. 
Although  a  cure  may  not  be  effected  in  all  cases,  the  operation 
is  followed  by  so  great  a  decrease  in  suffering  that  it  is  worthy 
of  consideration. 

Furthermore,  the  operation  has  been  so  improved  that 
the  mortality  from  it  is  less  than  2  per  cent,  in  the  hands  of 
competent  surgeons.  The  improved  technic  in  making  the 
anus  gives  the  patient  much  greater  control  over  the  bowel 
than  was  the  case  by  the  former  methods,  and  this,  to  a  large 
extent,  robs  the  operation  of  its  most  disgusting  feature.  As 
a  result  of  these  improvements,  together  with  the  fact  that 
artificial  ani  can  be  closed  with  comparative  safety  after  having 
served  their  purpose,  many  more  patients  are  now  being 
"colostomized"  than  formerly.  It  is  to  be  hoped  that,  in  the 
near  future,  the  operation  will  be  given  the  prominence  that 
it  deserves  among  the  surgical  procedures  for  the  relief  of  in- 
testinal diseases. 

Certainly  the  author's  experience  with  colostomy  has  been 
entirely  satisfactory  in  every  way.  His  colostomy  patients, 
who  have  come  from  the  various  walks  of  life,  have  in  but  very 
rare  instances  complained  of  the  almost  constant  dribbling  of 


584  DISEASES  OF  THE  RECTUM  AND  ANUS 

feces  through  the  artificial  anus  which  has  been  so  vividly  de- 
scribed by  opponents  of  the  operation.  On  the  contrary,  he 
has  been  compelled  to  treat  many  of  these  patients  for  consti- 
pation. While  the  author  is  a  firm  believer  in  both  temporary 
and  permanent  colostomy,  he  wishes  it  to  be  plainly  understood 
that  he  never  resorts  to  either  operation  until  all  other  palliative 
and  minor  surgical  procedures  for  the  relief  of  tJie  case  under  treat- 
ment have  been  unsucccssfidly  tried. 

Briefly  stated,  the  indications  for  colostomy  are  as  fol- 
lows : — 

1.  Congenital  malformations  of  the  rectum  in  which  the 
bowel  ends  in  a  blind  pouch  so  high  up  that  it  cannot  be  freed 
by  dissection  and  brought  down  and  united  to  the  skin  of  the 
anal  region. 

2.  Congenital  defects  of  the  bowel  in  which  the  feces  find 
an  outlet  through  the  bladder  or  urethra. 

3.  Otherwise  incurable  tubercular,  syphilitic,  dysenteric, 
or  catarrhal  ulceration  of  the  rectum  and  sigmoid. 

4.  Undilatable  and  inoperable  stricture  accompanied  by 
dangerous  symptoms  of  obstruction. 

5.  Polyposis  where  the  bowel  is  dotted  over  with  multiple 
small  and  large  polyps  which  bleed  freely,  become  ulcerated, 
and  produce  an  exhausting  discharge. 

6.  Otherwise  incurable  recto-vesical,  recto-urethral,  or 
recto-vaginal  fistula. 

7.  Volvulus  and  invagination  in  which  the  gut  is  gan- 
grenous and  the  condition  of  the  patient  too  critical  to  permit 
the  time  required  for  resection  and  anastomosis. 

8.  Extreme  dilatation  with  atony  of  the  colon,  giving  rise 
to  frequent  attacks  of  obstruction. 

9.  Otherwise  incurable  cases  of  procidentia  recti  in  which 
the  bowel  is  extremely  ulcerated  and  bleeds  easily  and  pro- 
fusely. 

10.  Paralytic  ileus  causing  dangerous  symptoms  of  ob- 
struction. 

11.  Fecal  impaction  which  cannot  be  relieved  by  other 
measures. 

12.  Obstruction  of  the  bowel  caused  by  foreign  bodies, 
enteroliths,  and  concretions  which  cannot  be  dislodged  and 
removed. 

13.  Otherwise  unrelieved  obstruction,  due  to  inflamma- 


COLOSTOMY  585 

tory  exudations  and  adhesions,  invol\'ing-  any  part  of  the  colon 
or  rectum. 

14.  Acute  or  chronic  obstruction  caused  by  inoperable 
tumors  of  the  pelvic  or  abdominal  organs. 

15.  Inoperable  cancer  involving  any  part  of  the  colon. 

16.  Operable  rectal-cancer  cases  in  which  the  growth  is 
extensive  and  the  rectum  is  to  be  subsequently  amputated  or 
resected  a  preliminary  colostomy  is  invaluable  because  it  per- 
mits the  bowel  to  be  emptied  of  impacted  feces,  prevents  the 
feces  from  contaminating  the  field  of  operation,  and  minimizes 
the  danger  of  fecal  infection  of  the  wound  after  the  amputation 
or  resection  of  the  diseased  bowel.  Moreover,  the  danger  of 
tearing  out  the  stitches  during  straining  at  stool,  resulting  in 
fecal  fistula  and  the  pain  incident  to  defecation,  is  ehminated. 
Again,  this  procedure  is  of  great  service  in  hastening  convales- 
cence where  retraction  of  the  bowel  has  followed  amputation. 
Certainly  healing  takes  place  m.ore  rapidly  and  the  patient's 
suffering  is  materially  lessened  after  excision  of  the  bowel  if 
the  ulcerated  surface  is  kept  free  from  fecal  matter  by  means 
of  preliminary  colostomy. 

17.  Chronic  atrophic,  hypertrophic,  membranous,  or 
stenosing  colo-proctitis  and  membranous  entero-colo-proctitis 
which  other  means  fail  to  relieve. 

18.  Any  disease  of  the  intestine  or  adjacent  structures 
which  produces  dangerous  symptoms  of  obstruction  and  in  those 
diseases  in  which  it  is  absolutely  necessary  to  give  the  bowel  rest 
and  protect  it  from  the  irritation  caused  by  the  passage  over  it 
of  the  excreta. 

19.  Exceptional  cases  of  complete  fecal  incontinence. 
While  in  a  large  number  of  cases  the  establishment  of  an 

artificial  anus  may  be  necessary  in  order  to  alleviate  or  cure 
the  above-named  affections,  the  operation  should  not  be  prac- 
ticed as  a  routine  procedure.  On  the  contrary,  such  patients 
should  not  be  "colostomized"  except  in  carefully  selected  cases 
in  which  the  symptoms  of  (a)  obstruction,  (b)  pain,  (c)  hem- 
orrhage, (d)  diarrhea,  or  (e)  discharge  are  so  urgent  that  it  is 
evident  the  patient  will  die  if  the  condition  is  not  reheved  or 
the  diseased  bowel  given  rest  from  the  constant  irritation  inci- 
dent to  contamination  by  the  feces  and  straining  during  defeca- 
tion. 

In  exceptional  cases  in  which  the  patient  is  known  to  have 


586  DISEASES  OF  THE  RECTUM  AND  ANUS 

an  incurable  ulceration,  stricture,  cancer,  or  other  affection  of 
the  sigmoid  or  rectum  which  causes  intense  suffering,  and  it  is 
quite  apparent  that  a  colostomy  will  be  necessary  eventually, 
it  is  much  more  desirable  to  make  the  artificial  anus  early,  be- 
fore dangerous  symptoms  develop,  and  thereby  save  the  patient 
much  unnecessary  suffering. 

As  the  indications  for  colostomy,  in  so  far  as  they  pertain 
to  diseases  of  the  rectum  and  anus,  have  been  fully  given  in  the 
separate  chapters  devoted  to  those  affections,  the  author  does 
not  consider  it  necessary  to  discuss  them  further  here. 


CLASSIFICATION 

There  are  five  varieties  of  colostomy.  Each  form  derives 
its  name  either  from  the  part  of  the  colon  which  is  opened  or 
the  region  in  which  the  artificial  anus  is  established. 

The  position  of  an  artificial  anus  in  any  case  should  depend 
upon  the  location  of  the  disease ;  in  other  words,  the  opening 
should  be  so  situated  that  it  will  not  become  involved  should  the 
disease  extend  upward. 

The  anus,  however,  should  not  be  placed  farther  above  the 
affected  part  of  the  gut  than  is  absolutely  necessary,  because, 
the  farther  the  opening  is  from  the  anus,  the  more  likely  is 
the  patient  to  be  annoyed  with  troublesome  incontinence  fol- 
lowing the  operation,  owing  to  the  fact  that  the  feces  are  liquid 
in  the  upper  part  of  the  large  bowel,  and  soHd  or  semisolid  in 
the  lower  colon  and  sigmoid. 

In  the  order  of  their  importance  the  different  varieties  of 
colostomy  are :  (1)  left  inguinal,  (2)  transverse,  (3)  right  inguinal, 
(4)  left  lumbar,  and  (5)  right  lumbar. 

Except  left  inguinal  and  left  lumbar  colostomy,  the  above 
forms  have  been  given  but  meager  consideration  by  writers 
generally,  and  very  properly  so,  because  they  are  applicable 
in  but  a  very  small  percentage  of  cases  requiring  colostomy. 

On  the  other  hand,  left  inguinal  and  left  lumbar  colostomy 
have  attracted  the  attention  of  surgeons  throughout  the  civil- 
ized world,  for  the  reason  that  these  operations  have  been  per- 
formed so  many  times.  During  the  past  fifteen  years  heated 
discussions,  as  to  their  relative  value,  have  been  carried  on  by 
operators  of  prominence.  Fortunately,  the  contention  is  at  an 
end,  and  the  verdict  has  been  rendered  in  favor  of  inguinal 


COLOSTOMY  5S7 

colostomy,  which  at  present  stands  high  in  favor.  This  is  due 
largely  to  the  untiring  efforts  of  Cripps,  Herbert  AUingham, 
Jesset,  Maydl,  Reeves,  Schede,  Treves,  Kelsey,  and  Polonson 
in  defending  this  method  of  treatment  and  in  pointing  out  its 
advantages  over  the  lumbar  operation.  The  change  in  the 
position  of  these  operations  has  been  radical.  Lumbar  colos- 
tomy— defended  by  Bryant,  of  London,  and  many  other  sur- 
geons of  his  day — was  the  favorite  prior  to  18S0 ;  but  since 
that  time  the  lumbar  has  been  entirely  superseded  by  the  in- 
guinal operation. 

In  the  author's  opinion,  there  are  many  and  excellent 
reasons  why  inguinal  is  preferable  to  lumbar  colostomy.  The 
advantages  of  the  inguinal  method  may  be  briefly  summed  up 
as  follows : — 

1.  Inguinal  colostomy  can  be  performed  under  general  or 
local  anesthesia  if  necessary. 

2.  A  smaller  incision  is  required;  it  is  less  difficult  and 
can  be  performed  much  more  quickly. 

3.  The  operation  is  not  delayed,  and  the  colon  is  not  diffi- 
cult to  locate  because  of  the  ample  space  which  facilitates  the 
work  of  the  operator  and  enables  him  to  trace  the  bowel  in 
either  direction  until  the  desired  part  is  found. 

4.  Because  of  the  free  incision,  there  is  no  excuse  for  mis- 
taking and  opening  any  other  viscus  for  the  colon. 

5.  There  is  little  difficulty  in  making  an  acute  spur  to  pre- 
vent the  feces  from  passing  over  and  reaching  the  diseased 
bowel  below  the  opening,  which  is  most  important. 

6.  Because  of  the  slight  tension  upon  the  sutures,  the  pain 
from  this  source  is  nil,  stitch-abscesses  are  uncommon,  and  re- 
traction of  the  gut  and  consequent  stricture  of  the  artificial 
anus  is  of  extremely  rare  occurrence. 

7.  The  wound  is  so  situated  that  the  patient  can  change 
his  posture  when  desired  without  causing  himself  additional 
pain. 

8.  The  mortality  (about  2  per  cent.)  is  very  much  less,  con- 
valescence is  more  rapid,  and  fewer  complications  occur  in 
inguinal  than  in  lumbar  colostomy. 

9.  Troublesome  procidentia  is  less  frequent  and  more 
easily  corrected  when  the  artificial  anus  is  in  the  groin. 

10.  Fecal  incontinence  is  less  frequent  because  the  feces 
are  more  solid  in  the  sigmoid  than  higher  up;    furthermore, 


588  DISEASES  OF  THE  RECTUM  AND  ANUS 

because  of  the  improved  technic  of  the  inguinal  operation,  the 
patient  is  better  able  to  control  the  fecal  discharges. 

11.  Unpleasant  accidents  can  usually  be  prevented,  as  a 
truss  can  be  comfortably  and  accurately  fitted  to  the  inguinal 
anus. 

12.  The  opening  is  located  in  front,  thus  enabling  the  pa- 
tient to  personally  cleanse  it  and  apply  the  necessary  dressings. 

13.  It  is  easier  to  irrigate  the  bowel  and  to  make  topic 
applications  to  the  diseased  rectum  from  above  than  after  lum- 
bar colostomy. 

14.  When  the  disease  for  which  the  opening  was  made  has 
been  healed,  the  artificial  anus  in  the  groin  can  be  closed  with 
less  difficulty. 

The  principal  advantages  claimed  for  lumbar  over  inguinal 
colostomy  are  as  follows : — 

1.  In  case  of  obstruction  the  distended  bowel  can  be 
opened  without  entering  the  peritoneal  cavity. 

2.  The  anus  being  higher,  the  disease  is  less  likely  to  ex- 
tend upward  from  the  rectum  and  involve  the  opening. 

3.  Prolapse  of  the  bowel  occurs  less  frequently  than  after 
the  inguinal  method. 

These  so-called  advantages  of  lumbar  colostomy  are  more 
imaginary  than  real,  as  the  up-to-date  surgeon  will  at  once  per- 
ceive. Before  the  advent  of  asepsis  and  antisepsis  it  was  ad- 
vantageous to  open  the  gut  without  injury  to  the  peritoneum, 
but,  under  modern  methods  of  operating,  this  causes  little 
apprehension.  Again,  it  must  be  borne  in  mind  that  it  is  fre- 
quently impossible  to  bring  the  bowel  up  sufficiently  to  attach 
it  to  the  skin  in  the  loin  without  incising  the  peritoneum.  The 
author  considers  it  wiser  to  open  the  abdomen  and  peritoneum 
freely  in  lumbar  colostomy,  as  is  done  when  an  inguinal  anus  is 
established.  The  operation  can  then  be  performed  with  rapidity 
and  precision,  which  is  better  than  to  attempt  to  work  through 
a  deep,  restricted  incision  with  a  bare  possibility  of  completing 
the  operation  without  having  entered  the  peritoneal  cavity. 

The  author  has  made  a  liberal  number  of  inguinal  colos- 
tomies, and  has  treated  many  patients  similarly  operated  upon 
by  other  surgeons.  He  has  never  seen  a  case  wherein  the  dis- 
ease had  extended  to  or  involved  an  inguinal  anus,  and  because 
of  this  experience  he  believes  that  this  complication  is  ex- 
tremely rare. 


COLOSTOMY  589 

Procidentia  may  occur  after  either  inguinal  or  lumbar 
colostomy,  but  in  the  author's  practice  it  has  happened  propor- 
tionately less  frequent  after  the  former  than  after  the  latter. 
The  author  has  not  performed  lumbar  colostomy  for  a  consid- 
erable time.  He  is  of  the  opinion,  however,  that  there  is  but 
one  condition  which  justifies  the  operation,  viz. :  in  cases  in 
zvhich  inguinal  colostomy  has  been  attempted  and  the  colon  is  so 
bound  dozvn  by  adhesions  and  inflammatory  exudations  that  it  is 
impossible  to  bring  the  bozvel  up  and  suture  it  to  the  skin  of  the 
inguinal  region.  In  such  instances  the  wound  in  front  should  be 
closed  immediately,  and  the  patient  turned  upon  the  side,  and  an 
artificial  anus  made  in  the  left  lumbar  region,  as  suggested  by  Mr. 
Herbert  W.  Allingham. 

LEFT  INGUINAL  (ILIAC)  COLOSTOMY  (SIQMOIDOSTOMY) 

Inguinal  colostomy  consists  in  opening  the  abdomen  in 
the  inguinal  region,  suturing  a  part  of  the  sigmoid  or  colon  to 
the  skin,  and  opening  it,  thus  forming  an  artificial  anus  through 
which  the  feces  are  expelled. 

Depending  upon  the  purpose  for  which  it  is  made,  an  in- 
guinal anus  may  be  : — 

1.   Permanent.  2.  Temporary. 

Permanent  Left  Inguinal  Colostomy. — This  form  of  artificial 
anus  is  by  far  the  most  common,  and,  when  the  term  colostomy 
is  used  without  specifying  the  variety,  this  form  is  usually  the 
one  referred  to  (Plate  XXXVI).  A  permanent  inguinal  anus 
is  established  in  certain  incurable  rectal  affections  (inoperable 
cancer,  stricture,  etc.)  as  a  palliative  measure,  and  also  in  cases 
in  which  the  rectum  is  to  be  subsequently  excised,  and  when 
the  disease  has  become  so  extensive  and  destructive  that  the 
function  of  the  bowel  is  permanently  impaired. 

Now  and  then,  however,  a  case  is  encountered  in  which,  as 
a  result  of  the  rest  given  to  the  bowel,  together  with  judicious 
topic  applications,  the  disease,  which  at  first  was  thought  to  be 
incurable,  heals  kindly  after  a  considerable  time,  leaving  but 
a  slight  impairment  of  the  function  of  the  rectum.  In  such 
cases  the  artificial  anus  should  be  closed  in  accordance  with  the 
methods  outlined  in  the  next  chapter. 

Some  authors  maintain  that,  when  the  fecal  current  has 
been  made  to  pass  out  through  the  groin  for  several  months 


590 


DISEASES  OF  THE  RECTUM  AND  ANUS 


or  years,  the  rectum  below  the  artificial  anus  becomes  atrophied 
and  useless,  and  that  for  this  reason  it  is  inadvisable  to  attempt 
to  close  this  false  passage  and  again  restore  the  normal  chan- 
nel. The  author  is  not  in  accord  with  such  teaching,  because 
in  several  instances  he  has  succeeded  in  closing  artificial  ani 
which  had  existed  for  periods  ranging  from  six  months  to 
three  years.  In  no  case  was  there  any  evidence  tliat  the  rectum 
had  undergone  even  sligJit  atrophic  changes.  One  of  these 
patients  was  a  young  woman  who  had  suffered  from  chronic 
ulceration,  which  healed  without  leaving  troublesome  stenosis; 
more  than  three  years  after  it  was  established  the  inguinal  anus 


Fig.  184. — A,  Showing  Location  and  Length  of  Incision  in  Left  Inguinal  Colos- 
tomy; B,  Line  of  Preliminary  Incision  when  the  Bowel  is  to  be  Carried 
Beneath  the  Skin  for  a  Distance  Before  it  is  Brought  Out  at  the  Usual 
Site. 


was  closed  by  freeing  the  ends  of  the  gut  from  their  abdominal 
attachments,  trimming  them  off,  and  making  an  end-to-end 
anastomosis  with  the  Murphy  button.  The  patient  made  a 
prompt  recovery.  From  the  date  when  she  was  first  allowed 
a  solid  diet  her  evacuations  were  normal  in  frequency  and  con- 
sistency, and  she  suffered  no  inconvenience  whatever  from  the 
establishment  of  the  artificial  anus. 

Technic  of  Left  Inguinal  Colostomy. — The  patient,  having 
been  prepared  as  for  any  other  abdominal  operation,  is  placed 
flat  upon  his  back  and  anesthetized  with  chloroform,  or  local 
anesthesia  may  be  employed  if  preferred. 

A    two-and-one-half    inch    (6.35    centimeters)    incision    is 


COLOSTOMY 


591 


made  about  two  inches  (5.08  centimeters)  to  the  inner  side  of 
the  left  anterior  superior  iliac  spine  and  almost  perpendicularly 
to  an  imaginary  line  from  the  spinous  process  to  the  umbilicus, 
one-third  of  the  incision  being  above  and  two-thirds  below  this 
Hne  (Fig.  184,  A).    The  cut  is  carried  through  the  skin  and  eel- 


Fig.  185.— Longitudinal  Bands  and  Appendices  Epiploicas. 

lular  tissue  down  to  the  abdominal  musculature  at  one  stroke. 
The  muscles  being  exposed,  their  fibers  are  separated  zvithout 
cutting,  as  suggested  by  Maydl;  the  muscles  are  recognized 
by  the  direction  of  their  fibers,  those  of  the  external  oblique 
passing  downward  and  inward;    those  of  the  internal  obhque, 


Colon  With 
no  mesentery 


Vertehral 
column 


Peritoneum 


Fig.  186. — No  Mesentery. 


downward  and  outward ;  and  those  of  the  transversalis  abdom- 
inis taking  a  transverse  direction.  As  soon  as  the  fibers  of  the 
transversalis  have  been  parted,  the  transversalis  fascia  comes 
into  view.  This  is  immediately  split,  and  the  incision  is  carried 
down  through  the  subserous  areolar  tissue  to  the  peritoneum, 


592 


DISEASES  OF  THE  EECTUM  AND  ANUS 


the  muscles  being  held  apart  by  retractors  while  the  dissections 
are  made.  Spurting  vessels  are  now  ligated,  oozing  is  arrested 
with  gauze  compresses  wrung  out  of  hot  water,  and  the  wound 
is  made  clean  before  entering  the  peritoneal  cavity.  The  peri- 
toneum is  divided  between  two  forceps,  and  the  incision  en- 


Co/i 
short  Jnesi 


-Peritoneum 


Fig.  187.— Short  Mesentery. 


larged,  using  the  finger  as  a  guard ;  when  thick,  and  adherent 
to  the  abdominal  wall,  the  peritoneum  is  ignored,  but  if  loose 
and  pliable,  it  may  be  brought  up  and  sutured  to  the  skin  with 
catgut  immediately  or  after  the  desired  part  of  the  gut  has  been 
isolated.    The  omentum,  which  frequently  bulges  out  and  com- 


Feritoneum 


Verlebral 
column 


Colon  with 
very  long 
mesenlertf 


Fig.  188.— Long  Mesentery. 


pletely  fills  the  wound,  is  held  aside  with  a  pad  of  gauze  while 
the  bowel  is  being  searched  for.  Ordinarily  the  sigmoid  can 
be  secured  by  passing  the  index  finger  into  the  belly  and  hook- 
ing up  the  first  piece  of  gut  which  is  felt.  Occasionally,  how- 
ever, several  loops  of  the  small  intestine  are  brought  out  before 
the  colon  is  caught,  and  in  rare  instances  it  is  necessary  to  en- 


COLOSTOMY 


593 


large  the  incision  and  introduce  the  whole  hand  into  the  abdo- 
men and  trace  the  bowel  down  from  the  transverse  colon  or 
up  from  the  pelvis.  When  the  sigmoid  cannot  be  located  in 
this  way,  a  colon-tube  should  be  inserted  and  the  bowel  dis- 
tended with  water  or  gas  until  it  comes  into  view. 

The  small  intestine  need  not  be  mistaken  for  the  colon, 
because  the  latter  can  be  recognized  by  its  larger  size,  thicker 
walls,  sacculations,  longitudinal  bands,  and  appendices  epiploiccB 
(Fig.  185).^  When  the  sigmoid  colon  has  been  located,  it  is 
withdrawn  through  the  wound  and  carefully  examined  to  see 


Fig.  189. — Schematic  Drawing  Showing  Variable  Lengths  of  the  Mesentery  and 
the  Distance  the  Bowel  can  be  Pulled  Out  Through  the  Incision. 


that  it  is  healthy.  The  condition  of  the  mesosigmoid  should  be 
noted,  because  the  success  of  the  spur  and  the  amount  of  the 
bowel  to  be  excised  depend  largely  upon  the  length  of  the 
mesentery.  When  the  mesentery  is  lacking  or  is  short  (Figs. 
186  and  187)  or  the  bowel  is  bound  down  by  adhesions,  it  is 
frequently  impossible  to  make  a  proper  spur,  owing  to  the  dif- 
ficulty in  obtaining  a  sufficient  angulation  of  the  gut.  On  the 
other  hand,  when  it  is  long  (Figs.  188  and  189),  no  embarrass- 
ment is  experienced  from  this  source;  indeed,  it  not  infre- 
quently becomes  necessary  to  amputate  several  inches  of  the 

1  Figures  185,  186,  187,  188,  192,  195,  196,  197,  198,  and  199  were  furnished  by  Mr. 
Herbert  W.  Allingham,  of  London,  with  the  chapter  on  colostomy  written  by  him  for 
the  previous  edition  of  this  work. 

38 


594 


DISEASES  OF  THE  RECTUM  AND  ANUS 


bowel,  as  advised  by  H.  W.  Allingham,  to  prevent  a  prolapse  of 
the  freely  movable  intestine  after  the  operation.  The  bowel  is 
pulled  upward  until  it  is  taut  (Figs.  189  and  192),  both  from 
above  and  below  the  opening;  a  spur  is  now  made,  and  the 
bowel  fastened  to  the  abdominal  wall  by  the  introduction  of  a 
silk,  silk-worm,  or  chromicized  catgut  suture  passed  through 
the  skin,  serosa,  and  musculature  (or  mesentery)  of  the  afferent 
leg  of  the  intestinal  loop  and  then  carrying  it  across  the  mesen- 
tery. The  suture  is  then  brought  out  through  the  peritoneal 
and  muscular  coats  (or  mesentery)  of  the  efferent  leg,  and  finally 
through  the  skin  at  a  point  half  an  inch  (1.27  centimeters)  from 
its  entrance   (Figs.  190,  191,  and  199).     The  two  ends  of  the 


"X 

>4    ^^^ 

% 

hm^                            "^' 

?.'■ 

^'^ 

~l^ 

^ 

i 

Fig.  190. — Manner  of  Placing  the  Mesenteric  Suture  in  Left  Inguinal  Colostomy. 


suture  are  now  grasped  and  pulled  upward  until  the  upper  and 
lower  ends  of  the  loop  are  drawn  together,  when  they  are  tied, 
thus  anchoring  the  sigmoid  to  the  wound.  The  length  of  the 
abdominal  incision  is  shortened  by  sutures  of  catgut  until  the 
opening  left  through  Avhich  the  gut  protrudes  is  not  more  than  an 
inch  and  a  half  (3.81  centimeters)  in  length  (Fig.  191).  The 
stitches  in  the  angles  of  the  wound  above  and  below  the  bowel 
should  be  made  to  pass  beneath  the  heavy  longitudinal  band 
(Fig.  190)  which  courses  along  the  center  of  the  outer  surface 
of  the  protruding  gut. 

To  prevent  the  possibility  of  a  hernia,  the  bowel  is  attached 
to  the  edges  of  the  wound  by  interrupted  sutures  of  fine  catgut 
placed  about  half  an  inch  (1.27  centimeters)  apart  and  including 


COLOSTOMY  595 

the  skin  and  the  serous  and  muscular  coats  of  the  intestine 
(Fig.  191). 

A  piece  of  protective  tissue,  smeared  with  sterile  vaselin, 
is  placed  over  the  gut ;  a  wall  is  then  built  up  around  the  pro- 
truding bowel  with  a  thick  gauze  rope,  in  order  to  prevent 
undue  pressure  upon  it  when  the  outer  dressings  and  abdominal 
binder  are  applied. 

The  patient  is  then  placed  in  bed  and  kept  as  quiet  as 
possible.  The  nurse  should  be  instructed  to  make  gentle  press- 
ure with  the  hollow  of  the  hand  placed  over  the  knuckle  of 
intestine  during  attacks  of  vomiting,  in  order  to  diminish  the 
strain  and  prevent  a  possible  hernia.  A  fluid  diet  is  adhered  to 
and  sufficient  morphine  given  to  ease  pain,  until  after  the  bowel 
is  opened,  which  may  be  in  a  few  hours,  or  not  for  several  days, 
depending  upon  the  amount  of  distension.  As  a  rule,  these 
patients  suffer  very  little  pain,  except  when  gas  collects  in 
the  knuckle  of  gut.  When  adhesions  have  formed  entirely 
around,  between  the  intestine  and  the  abdominal  wall,  the 
bowel  is  amputated  to  within  a  quarter  of  an  inch  (0.64  centi- 
meter) of  the  skin  (Fig.  198).  Bleeding  is  arrested  and  dress- 
ings applied,  always  covering  the  wound  with  protective  tissue. 

Temporary  (Provisional)  Left  Inguinal  Colostomy. — It  is  only 
in  the  past  few  years  that  surgeons  have  appreciated  the 
good  results  to  be  had  from  the  formation  of  a  temporary  arti- 
ficial anus  for  the  relief  of  certain  varieties  of  otherwise  incurable 
affections  of  the  colon,  sigmoid,  rectum,  and  anus.  The  pro- 
visional artificial  anus  has. attained  its  present  popularity  (a) 
because  of  the  benefits  derived  from  the  operation;  (h)  the 
fact  that  these  patients  are  less  frequently  annoyed  by  fecal 
incontinence,  as  a  result  of  the  improved  technic;  and  (c)  be- 
cause it  is  now  known  that  the  opening  in  the  groin  can  be 
closed  with  comparatively  little  danger,  when  the  disease,  for 
the  relief  of  which  the  anus  was  established,  has  been  removed 
or  healed.  This  operation  is  indicated  for  the  relief  of  obstinate 
syphilitic,  tubercular,  dysenteric,  and  traumatic  ulceration; 
certain  forms  of  stricture,  hypertrophic  or  atrophic  catarrh 
of  the  colon  and  rectum,  and  membranous  entero-colo-proc- 
titis ;  also  as  a  preliminary  procedure  to  amputation  or  re- 
section of  the  rectum  or  sigmoid  in  which  it  is  specially  desirable 
to  keep  the  feces  away  from  the  field  of  operation,  and  to  avoid 
the  straining  incident  to  defecation,  as  well  as  the  danger  of 


596  DISEASES  OF  THE  RECTUM  AND  ANUS 

infection  from  this  source.  Finally,  the  operation  is  justifiable 
in  any  case  in  which  it  is  necessary  to  give  the  bowel  absolute 
rest. 

The  first  steps  in  the  operation  for  the  formation  of  a  tem- 
porary  inguinal  anus  are  the  same  as  if  the  opening  was  to  be  per- 
manent, but  differs  from  it  in  the  manner  of  opening  the  bowel. 
In  making  a  provisional  colostomy  it  should  be  borne  in  mind 
that  the  opening  is  to  be  closed  in  a  short  time.  This  is  more 
easily  accomplished  when  the  entire  circumference  of  tJie  bozvel  is 


Fig.  191. — Appearance  of  Wound  and  Bowel  at  the  Close  of  the  Operation  of 
Left  Inguinal  Colostomy  when  the  Gut  has  not  been  Opened. 

not  divided,  as  is  done  in  those  instances  in  which  the  anus  is  to 
be  permanent.  In  this  class  of  cases  the  writer  would  empha- 
size that  no  part  of  the  gut  should  be  cut  away,  but  that  the 
bowel  be  opened  by  a  longitudinal  incision  about  an  inch  and  a 
half  (3.81  centimeters)  in  length,  made  in  the  center  of  the  most 
prominent  part  of  the  protruding  intestine.  Some  surgeons  ad- 
vise a  transverse  cut,  but,  in  the  author's  experience,  this  has 
not  proven  advantageous  in  any  way ;  indeed,  he  has  found  it 
more  difficult  to  mend  the  bowel  afterward  than  when  a  longi- 
tudinal incision  has  been  made. 


COLOSTOMY  597 

In  order  to  make  an  artificial  anus  which  can  be  closed 
when  desired,  Tuttle  performs  Maydl's  operation,  except  that 
he  does  not  unite  the  peritoneum  to  the  skin.  After  waiting 
at  least  a  week  for  adhesions  to  form  between  the  bowel  and 
abdominal  wall,  he  proceeds  as  follows : — ■ 

"A  linear  incision  through  the  center  of  the  protruding  gut 
is  made  from  the  upper  angle  of  the  wound  to  a  point  one-half 
inch  (1.27  centimeters)  below  the  glass  rod  supporting  the 
intestine.  A  transverse  incision  is  then  made  at  this  point, 
extending  two-thirds  of  the  way  around  the  gut.  The  two 
triangular  flaps  attached  to  the  upper  segment  of  the  gut  will 
then  pass  downward  and  outward,  because  the  fecal  current  will 
continually  push  them  in  this  direction,  whereas  the  transverse 
flap  of  the  lower  sigmoid  of  the  gut  will  fall  downward  and  in- 
ward, practically  occluding  the  passageway  to  the  rectum, 
and  so  long  as  the  rod  remains  in,  or  the  spur  of  the  intes- 
tine is  held  at  its  original  level,  there  will  be  no  passage  of  fecal 
matter  below  the  inguinal  anus. 

"It  will  thus  be  seen  that  no  portion  of  the  intestine  is  re- 
moved, and,  when  the  time  comes  for  closing  such  an  anus,  all 
of  the  original  wall  of  the  intestine  will  be  left  to  act  upon. 
These  triangular  flaps  roll  backward  and  curl  up  like  a  dried 
leaf  in  the  winter-time,  and  produce  very  little  protrusion  from 
the  abdominal  wall.  If,  at  any  time,  it  is  determined  to  make 
the  temporary  anus  a  permanent  one,  they  can  be  cut  off  with 
the  scissors  without  any  danger  or  inconvenience  and  very  little 
pain  to  the  patient. 

"When  the  time  comes  for  closing  the  anus,  the  triangular 
flaps,  which  have  been  rolled  back  upon  each  side,  can  be  dis- 
sected loose  and  unrolled  and  the  lower  one  can  be  lifted  up, 
and  thus  the  whole  caliber  of  the  gut-wall  restored.  They  are 
then  sutured  in  their  original  place,  first  with  a  silk  suture 
through  the  mucus  membrane  alone,  thus  closing  up  the  gut. 
A  row  of  Lembert  catgut  sutures  is  then  applied  along  the  line 
of  the  original  incision  into  the  gut.  The  gut  is  thus  closed 
without  entering  the  peritoneal  cavity;  but  still  the  spur  re- 
mains. Now,  to  overcome  this,  the  intestine  is  dissected  loose 
from  the  original  abdominal  wound,  until  the  lower  surface  of 
the  muscles  is  reached.  The  parietal  peritoneum  is  then  de- 
tached from  the  abdominal  wall  for  a  space  of  about  one  or  two 
inches  (2.54  or  5.08  centimeters)  around  the  wound,  thus  form- 


598  DISEASES  OF  THE  EECTUM  AND  ANUS 

ing  a  loose  loop,  which  allows  the  intestine  to  fall  downward, 
and  thus  destroy  the  acuteness  of  the  spur. 

"The  edges  of  the  muscles,  skin,  and  fascia  are  then  fresh- 
ened and  drawn  together  with  silk-worm-gut  sutures  over  the 
intestine.  It  will  thus  be  seen  that  the  whole  artificial  anus  and 
abdominal  opening  will  have  been  closed  without  entering  the 
peritoneum,  and  almost  absolutely  without  danger  to  the  pa- 
tient." Dr.  Tuttle  has  reported  seven  cases  successfully  treated 
by  this  method. 

The  author'has  resorted  to  the  above  procedure  in  but  one 
case ;  in  this  instance  the  Haps  atrophied  and  the  artificial  anus 
was  closed  by  resection  and  end-to-end  anastomosis  with  the 
Murphy  button. 

The  different  methods  of  closing  artificial  ani  and  fecal  fist- 
ulas will  be  fully  described  in  the  next  chapter. 


TRANSVERSE   COLOSTOMY 

As  its  name  implies,  transverse  colostomy  signifies  the 
making  of  an  artificial  anus  by  lifting  a  part  of  the  transverse 
colon  up  to  and  attaching  it  to  the  external  abdominal  parietes 
above  the  umbilicus  (usually  in  the  median  line),  when  the 
bowel  is  then  opened. 

Transverse  and  right  inguinal  colostomy  are  rarely  per- 
formed, because  most  of  the  affections  (cancer,  stricture,  ulcer- 
ation, etc.)  for  the  relief  of  which  an  artificial  anus  is  made  are, 
in  the  vast  majority  of  cases,  located  in  the  rectum  or  lower 
sigmoid,  and  can  be  relieved  by  an  inguinal  anus. 

When  it  has  been  determined  positively,  after  a  careful 
examination  (under  general  anesthesia  when  necessary)  that 
the  disease  is  located  either  in  the  upper  sigmoid,  splenic  flex- 
ure, or  the  left  half  of  the  transverse  part  of  the  large  bowel, 
transverse  colostomy  is  indicated. 

The  technic  for  this  operation  is  about  the  same  as  that 
for  left  inguinal  colostomy,  fa)  except  that  the  abdominal  in- 
cision is  made  in  the  median  line,  and  (b)  not  so  much  of  the 
bowel  is  brought  up,  sutured  to  the  wound,  and  afterward  am- 
putated, because  the  mesentery  is  not  so  lengthy  and  proci- 
dentia is  less  apt  to  follow  the  operation. 

In  all  cases  of  suspected  serious  disease  of  the  large  intes- 
tine, a  free  median  incision  should  be  made  and  the  affected 


COLOSTOMY  599 

part  located.    The  artificial  anus  can  then  be  established  wher- 
ever it  will  do  the  most  good, 

RIGHT   INGUINAL   COLOSTOMY 

This  operation  is  indicated  when  the  disease  causing  ob- 
struction, hemorrhages,  diarrhea,  and  other  dangerous  symp- 
toms is  located  in  the  right  half  of  the  transverse  colon,  hepatic 
flexure,  and  ascending  colon.  A  right  inguinal  anus  is  made 
in  exactly  the  same  manner  as  when  the  opening  is  located  in 
the  left  groin,  with  the  exception  that  less  of  the  bowel  can  be 
drawn  out,  because  it  is  less  movable,  owing  to  the  shorter 
mesentery  on  the  right  side. 

LEFT   LUMBAR   COLOSTOMY 

In  this  procedure  the  colon  is  incised  and  fastened  to  the 
integument  in  the  left  loin  or  lumbar  region.  Bryant,  of 
London,  probably  performed  this  operation  more  frequently 
than  any  other  surgeon,  and  his  technic  in  performing  the 
operation  was  greatly  admired  when  this  procedure  was  at  the 
height  of  its  popularity.  He  describes  the  operation  as  fol- 
lows : — 

"The  patient  is  to  be  placed  on  his  right  side,  with  a  pihow 
beneath  the  loin,  in  order  to  arch  somewhat  the  left  flank,  and 
he  should  be  turned  two-thirds  over  on  his  face ;  the  outer 
border  of  the  erector  spinse  and  of  the  quadratus  lumborum 
can  then  be  made  out,  this  latter  muscle — which  is  on  a  deeper 
plane — being  the  surgeon's  main  guide.  Its  outer  border,  with 
the  descending  colon,  is  to  be  found  one-half  to  one  inch  (1.27 
to  2.54  centimeters)  posterior  to  the  center  of  the  crest  of  the 
ilium,  the  center  being  the  point  midway  between  the  anterior 
and  posterior  spinous  processes. 

"An  incision  is  then  to  be  made,  four  or  five  inches  (10.16 
to  12.7  centimeters)  long,  beginning  an  inch  and  a  half  (3.81 
centimeters)  to  the  left  of  the  spine,  below  the  last  rib,  and 
passing  downward  and  forward  parallel  with  the  crest  of  the 
ilium ;  the  line  of  the  incision  should  pass  obliquely  across  the 
external  border  of  the  quadratus  lumborum,  about  its  center, 
so  as  to  take  the  same  direction  as  the  nerves  which  traverse 
this  part.  By  this  incision,  the  integuments  and  muscle  and 
fascia  are  divided  and  the  outer  border  of  the  quadratus  mus- 
cle exposed.     The  abdominal  muscle  can  be  divided  to  give 


600  DISEASES  OF  THE  RECTUM  AND  ANUS 

room.  All  vessels  are  now  to  be  secured.  The  transversalis 
fascia  will  next  come  into  view,  and  beneath  this  will  be  the 
colon,  a  layer  of  fat  intervening.  The  bowel  can  always  be 
found  in  front  of  the  lower  border  of  the  kidney.  This  organ 
should,  consequently,  be  sought,  as  it  is  the  only  certain  guide 
to  the  bowel.  When  distended,  the  bowel,  on  dividing  the 
fascia,  comes  at  once  under  the  eye;  but,  when  empty,  some 
little  trouble  is  experienced  in  hooking  it  up  with  the  finger. 

"When  the  bowel  has  been  caught,  it  should  be  partially 
rolled  forward  in  order  to  expose  its  posterior  surface;  for  if 
this  be  not  done,  there  is  a  risk  of  the  surgeon  wounding  the 
peritoneum  where  it  is  reflected  from  its  anterior  surface  on  to 
the  abdominal  wall.  The  bowel,  having  been  drawn  up  to  the 
wound,  is  then  to  be  secured  to  the  integument,  and  not  to  the 
muscles,  by  the  passage  of  ligatures,  introduced  through  one 
margin  of  the  wound,  then  through  the  bowel,  and,  last, 
through  the  outer  margin.  The  bowel  can  then  be  opened  by 
an  incision  about  half  an  inch  (1.27  centimeters)  long  between 
the  lip:atures  that  have  traversed  its  canal ;  the  centers  of  the 
ligatures  are  then  to  be  drawn  out  through  the  wound  and 
divided,  the  two  halves  of  the  Hgatures  fixing  the  two  sides  of 
the  divided  intestine  firmly  to  the  margins  of  the  wound;  two 
or  more  stitches  may  then  be  introduced,  to  make  the  artificial 
anus  secure." 

The  gut,  as  in  the  inguinal  method,  may  be  opened  imme- 
diately or  not  until  several  days  after  the  preliminary  operation. 

RIGHT   LUMBAR   COLOSTOMY 

Right  lumbar  colostomy  is  performed  in  the  same  manner 
as  the  operation  just  described,  except  the  artificial  anus  is 
made  in  the  right  instead  of  the  left  loin.  The  operation  is 
justifiable  only  in  cases  in  which  the  bowel  is  bound  down  to 
such  an  extent  that  it  is  impossible  to  bring  it  up  and  suture 
it  to  the  skin  of  the  right  inguinal  region. 

AFTER=TREATMENT 

The  after-treatment  for  the  different  varieties  of  colostomy 
is  about  the  same.  These  patients  complain  of  but  very  little 
pain  except  when  gas  accumulates  in  the  knuckle  of  gut ;  in 
such  cases  they  are  given  an  opiate  to  relieve  their  suffering. 
Patients  who  have  been  colostomized  are  to  be  restricted  to  a 


COLOSTOMY  601 

Mdd  diet  until  the  bowel  has  been  opened.  Then  they  are  im- 
mediately given  solid  food  to  make  the  feces  more  firm  and 
thereby  diminish  the  number  of  stools.  When  obstruction  has 
been  almost  complete,  causing  fecal  impaction,  and  the  diseased 
bowel  is  very  irritable,  the  patients  are  annoyed  considerably 
for  the  first  week  or  two  following  the  operation  by  the  frequent 
soiling  of  the  dressings.  However,  as  has  been  stated  else- 
where, the  frequency  of  the  involuntary  actions  gradually  di- 
minishes when  the  bowel  is  properly  trained,  until  in  most  cases 
there  are  but  two  actions  daily :  one  after  breakfast  and  the 
other  just  before  retiring.  In  exceptional  instances,  in  which 
the  bowel  does  not  act  for  several  days  after  the  operation, 
some  reliable  cathartic  is  given. 

The  soreness  caused  by  the  removal  of  the  bowel  and  the 
cutting  out  of  the  stitches  soon  disappears  when  the  raw  sur- 
face is  made  to  heal  by  cleanliness  and  gentle  stimulation. 
Most  of  these  sufferers  are  out  of  bed  in  from  six  to  eight  days 
and  are  discharged  from  the  hospital  at  the  end  of  the  second 
week.  From  that  time  onward  the  only  dressing  they  require 
is  a  piece  of  gauze  over  which  is  placed  a  pad  of  cotton  and  an 
abdominal  binder  to  protect  their  clothing.  The  bandage  may 
be  prevented  from  slipping  upward  by  means  of  a  strap  fastened 
to  it  behind,  carried  between  the  legs  and  adjusted  to  the  lower 
end  of  the  binder  in  front  by  means  of  a  buckle  placed  below  the 
opening. 

GENERAL   REMARKS   ON   COLOSTOMY 

The  selection  of  an  anesthetic  is  always  an  important  feature 

of  the  operation.  The  author,  as  above  indicated,  very  much 
prefers  chloroform  to  ether  in  these  cases,  because  the  patient 
yields  to  the  former  much  more  quickly  and  is  less  apt  to  strug- 
gle and  vomit  during  and  after  the  operation :  complications 
which  should  be  avoided  when  possible.  When,  for  any  reason, 
ether  is  used,  it  is  preceded  by  the  administration  of  laughing- 
gas.  The  author  has,  on  three  occasions  (all  in  elderly  people), 
succeeded  in  performing  left  inguinal  colostomy  and  caused 
his  patients  but  slight  pain  (except  at  the  time  tension  was 
made  upon  the  mesentery)  by  injecting  the  skin,  cellular  tissue, 
and  muscles  of  the  abdomen  with  a  1-per-cent.  eucaine  solu- 
tion, using  altogether  about  a  drachm  of  the  solution  in  each 
instance.      In   none   of   these   cases   was   there   any   unpleasant 


602  DISEASES  OF  THE  RECTUM  AND  ANUS 

effects  from  the  drug  during  or  following  the  operation.  He 
has  also  performed  the  operation  successfully  under  anesthesia 
produced  by  distending  the  tissues  with  sterile  water  or  weak 
solutions  of  eucaine  or  cocaine. 

The  opening  in  the  abdominal  wall  should  not  be  made  too 
small,  less  than  an  inch  (2.54  centimeters)  long.  This  is  neces- 
sary in  order  to  avoid  the  danger  of  stricture  should  contrac- 
tion be  marked.  Nor  should  the  opening  be  too  large,  more 
than  an  inch  and  a  half  (3.81  centimeters)  in  length,  as  a  wide, 
open,  artificial  anus  invites  both  procidentia  and  fecal  incon- 
tinence. 

The  method  of  dealing  with  the  peritoneum  is  not  so  impor- 
tant a  part  of  the  operation  as  many  writers  would  imply.  It 
really  makes  very  little  difference  whether  the  peritoneum  is 
sutured  to  the  skin  in  order  to  secure  union  between  it  and  the 
serosa  of  the  bowel  (Fig.  191)  or  whether  it  is  ignored  and  the 
bowel  sutured  to  the  integument  so  that  adhesions  are  formed 
between  it  and  the  musculature.  Should  the  peritoneum  be  dif- 
ficult to  bring  up  into  the  wound,  the  writer  leaves  it  alone  and 
unites  the  gut  to  the  cut  surface  of  the  abdominal  wound,  as 
suggested  by  Reclus.  When  the  intestine  is  carefully  sutured 
to  the  wound,  there  is  little  danger  of  retraction  or  of  the  bowel 
dropping  back  into  the  abdomen  after  either  method.  The 
author  has  tested  both  procedures  on  several  occasions  when 
he  has  made  a  resection  or  amputation  of  the  rectum,  follow- 
ing a  provisional  colostomy  performed  some  days  or  weeks 
before.  In  no  case  has  the  bowel  been  detached  from  the  ab- 
dominal parietes,  although  considerable  tension  was  made  upon 
it  from  below  in  order  to  draw  the  diseased  gut  down  suffi- 
ciently for  it  to  be  extirpated.  When  there  is  great  distension 
and  it  is  imperative  that  the  bowel  be  opened  immediately  or 
within  a  few  hours  following  the  operation,  the  peritoneum 
should  be  sutured  to  the  skin.  By  such  a  procedure  there  is  less 
danger  of  peritoneal  infection  from  fecal  contamination,  owing 
to  the  fact  that  union  between  the  two  peritoneal  surfaces  takes 
place  much  more  quickly  than  when  the  serosa  of  the  bowel  is 
sutured  to  the  cut  surface  (musculature  of  the  abdominal 
parietes). 

The  amount  of  bowel  to  be  removed  varies  in  different  cases, 
depending  upon  the  presence  of  adhesions  and  more  especially 
upon  the  length  of  the  mesentery.    The  position  of  the  perito- 


COLOSTOMY 


603 


neum  and  length  of  the  mesentery  differ  materially  in  a  large 
series  of  cases.  Mr.  Herbert  W.  Allingham  has  made  an  ex- 
haustive study  of  the  mesenteric  attachments  of  the  colon  and 
sigmoid,  and  has  fully  pointed  out  the  necessity  of  properly 
handling  the  mesentery  in  colostomy  operations  of  every  de- 
scription in  order  that  a  successful  artificial  anus  may  be  estab- 
lished and  a  prolapse  of  the  bowel  through  the  opening  avoided 
in  after-years.  He  divides  mesenteries  into  the  short,  when 
there  is  practically  none;  the  medium,  where  it  is  from  two  to 
three  inches  (5.08  to  7.62  centimeters)  in  length;  and  long, 
when  it  reaches  five  inches  (12.7  centimeters)  or  more  in  length 
(Figs.  186,  187,  and  188). 

In  performing  left  inguinal  colostomy  the  author  follows 
Allingham's  plan  of  making  the  gut  taut  by  drawing  it  out  from 


Fig.  192. —Mesentery  made  Taut. 


above  and  from  below  before  it  is  sutured  to  the  skin  (Figs. 
189  and  192).  Sometimes  only  a  small  loop  of  the  intestine  is 
anchored  and  later  cut  away ;  in  other  cases  in  which  the  mesen- 
tery is  quite  long,  from  three  to  twelve  inches  (7.68  to  30.62 
centimeters)  of  the  bowel  is  amputated  in  order  to  provide 
against  a  future  procidentia.  Owing  to  adhesions  or  the  ab- 
sence of  a  mesentery,  it  is  sometimes  impossible  to  do  more 
than  bring  the  upper  surface  of  the  bowel  up  sufficiently  to 
unite  it  to  the  skin.  This  is  a  very  unfortunate  condition,  for 
the  reason  that  it  is  impossible  in  such  cases  to  make  a  proper 
spur  and  thus  prevent  all  of  the  feces  from  passing  over  the 
diseased  bowel  below  the  opening.  AVhenever  possible,  the 
entire  circumference  of  the  bowel  should  be  brought  above  the 
level  of  the  skin  (Figs.  189  and  192) ;  so  that  when  it  is  excised 
a  bridge  of  intestine  will  not  be  left  to  guide  the  feces  from  the 


604 


DISEASES  OF  THE  RECTUM  AND  ANUS 


colon  above  into  the  rectum  below,  forming  a  fecal  Ustiila  (Fig. 
193)  instead  of  an  artificial  anus  (Fig.  194). 

The  sigmoid  should  be  drawn  out  a  sufficient  distance,  and 
the  spur  so  made  that  the  afferent  and  efferent  legs  of  the  in- 
testinal loop  become  agglutinated  and  remain  parallel.  This  is 
necessary  in  order  to  secure  two  distinct  openings  when  the 
protruding  piece  of  gut  is  cut  or  clamped  (Figs.  195  and  196) 
away,  which  gives  to  the  artificial  anus  an  appearance  not  un- 
Hke  the  muzzle  of  a  double-barreled  shotgun  (Fig.  197  and 
Plate  XXXVI).  When  this  has  been  accomplished,  it  is  prac- 
tically impossible  for  the  feces  to  escape  into  the  diseased  bowel 
below. 

The  bowel  should  never  be  amputated  on  a  level  with  the  skin, 


Fig.  193.— Artificial  Anus  Improperly  Made,  Showing  how  the  Feces  may  Escape 
both  Through  the  Opening  in  the  Groin  and  into  the  Rectum. 


as  is  advised  by  some  surgeons,  because  of  the  danger  of  in- 
fecting the  peritoneal  cavity,  should  retraction  take  place  dur- 
ing the  act  of  coughing  or  vomiting.  The  author  lost  one  pa- 
tient from  this  cause  several  years  ago,  and  since  then  it  has 
been  his  practice  to  leave  from  one-fourth  to  half  an  inch  (0.63 
to  1.27  centimeters)  of  the  gut  projecting  above  the  integu- 
ment, as  practiced  by  Allingham  (Fig.  198).  The  protruding 
rim  of  intestine  does  not  cause  any  additional  annoyance,  and 
soon  disappears,  especially  if  it  is  occasionally  cauterized  with 
copper  sulphate. 

Whenever  there  is  any  probability  that  the  new  anus  will 
be  closed,  the  entire  circumference  of  the  bowel  should  not  be 
divided,  except  when  imperative,  in  order  that  a  proper  spur 
may  be  formed.     On  the  contrary,  the  bowel  should  be  opened, 


COLOSTOMY 


605 


rather  than  amputated,  according-  to  the  plan  outhned  in  deal- 
ing with  a  temporary  opening  into  the  bowel. 

The  time  for  opening  the  bowel  after  it  has  been  anchored 
outside  the  abdomen  depends  upon  the  amount  of  obstruction 
and  distension  present  during  and  following  operation.  In  a 
large  majority  of  instances  these  symptoms  will  not  be  espe- 
cially troublesome,  and  the  intestine  need  not  be  opened  for 
several  days  (from  four  to  eight),  or  until  it  is  certain  that  ad- 
hesions have  formed  all  the  way  around  between  the  gut  and 
abdominal  parietes  zvJiich  zvill  eifectively  prevent  infection  of  the 
peritoneum  by  the  feces  when  the  latter  are  permitted  to  escape. 
On  the  other  hand,  an  outlet  should  be  rriade  for  the  intestinal 
contents,  during  the  operation,  a  few  hours  or  one,  two,  or 
three  days  after  the  operation,  whenever  the  patient's  condition 


Fig.  194. — Artificial  Anus  Properly  Made  with  Spur,   Showing  the  Manner  in 
which  All  the  Feces  Find  an  Exit  Through  the  Groin. 


becomes  critical  from  exhaustion,  intense  suffering,  or  when 
there  is  imminent  danger  of  intestinal  rupture  from  increasing 
distension.  In  several  cases  in  which  it  was  necessary  to  open 
the  gut  before  agglutination  of  the  intestine  and  abdominal 
wall  had  taken  place  the  author  resorted  to  a  modification  of 
Panl's  method  of  opening  the  intestine,  and  was  very  much 
pleased  with  it.  There  is  certainly  much  less  danger  of  the 
wound  becoming  infected  from  the  feces  after  this  method  than 
after  the  methods  suggested  by  other  surgeons  to  accomplish 
the  same  purpose.  Paul's  plan  is  to  divide  the  sigmoid,  in- 
vaginate  and  suture  the  distal  end  of  the  gut,  and  drop  it  back 
into  the  abdomen;  he  then  places  a  double-rimmed  glass  tube 
into  the  proximal  end  of  the  bowel  and  secures  it  by  tying  a 
ligature  around  the  gut  at  a  point  between  the  two  rims;    a 


606 


DISEASES  OF  THE  RECTUM  AND  ANUS 


long  rubber  drainage-tube  is  then  attached  to  the  other  end  of 
the  glass  tube,  through  which  gas  and  feces  escape,  but  at  a 
safe  distance  from  the  wound.  The  projecting  bowel  is  re- 
moved after  three  days.  Where  the  disease  is  located  in  the 
sigmoid,  he  extirpates  it  and  places  a  tube  in  both  ends  of  the 
divided  bowel.     He  afterward  sutures  the  bowel  together  for 


Fig.  195.— Herbert  Allingham's  Colotomy  Clamp. 

three  inches  (7.62  centimeters)  below  where  it  is  attached  to  the 
skin  in  order  to  form  a  good  spur. 

The  author  does  not  divide  the  bowel,  but  throws  a  purse- 
string  suture  of  silk  around  the  part  of  the  bowel  to  be  opened. 
The  wound  is  protected  by  placing  a  piece  of  gauze  under  the 
intestinal  loop ;  the  piece  of  gut  encircled  by  the  suture  is  then 
lifted  up,  grasped,  and  incised  between  two  catch  forceps;    a 


Pig.  196.— Removal  of  Gut  with  Above  Clamp. 


specially-made,  hard-rubber  tube,  half  an  inch  (1.27  centime- 
ters) in  diameter,  is  then  quickly  inserted  and  the  ligature  tied 
around  its  grooved  end.  The  rubber  drain  is  then  attached  as 
in  Paul's  operation.  This  procedure  requires  but  a  few  min- 
utes, during  which  time  but  a  small  amount  of  gas  and  feces 
escapes.  The  relief  afforded  by  this  procedure  is  inestimable. 
The  mortality  following  this  method  of  treating  the  bowel  in 


COLOSTOMY  607 

this  class  of  cases  is  very  much  less  than  it  is  in  those  instances 
in  which  the  bowel  is  divided  and  the  two  ends  of  the  intestine 
are  stitched  to  the  wound,  as  is  done  by  some  operators.  After 
the  latter  procedure  the  wound  is  almost  certain  to  become 
infected  from  the  frequent  discharge  of  gas  and  feces  through 
and  over  it. 

Robson  has  succeeded  in  reducing  the  distension  in  these 


Fig.  197. — Double-Barreled  Opening. 

cases  by  puncturing  the  bowel  with  a  trocar  and  then  guiding 
the  gas  and  feces  away  from  the  wound  by  attaching  a  rubber 
tube  to  the  cannula  left  in  the  bowel.  This  plan,  however,  is 
more  dangerous  and  less  reliable  than  the  one  practiced  by 
either  Paul  or  the  author. 

The  author  would  once  more  emphasize  the  danger  of 
opening  the  bowel  before  adhesions  have  formed,  except  in  a 
few  cases  in  which  the  distension  is  alarming.     In  his  experi- 


Fig.  198.— Removal  of  Gut  Above  the  Skin. 

ence,  the  mortality  following  the  establishment  of  artificial  ani 
in  cases  in  which  the  bowel  was  opened  during  or  shortly  fol- 
lowing the  operations  has  been  very  much  higher  than  when 
this  part  of  the  operation  was  delayed  for  several  days. 

The  formation  of  an  efficient  spur  is  by  far  the  most  impor- 
tant step  in  the  establishment  of  a  successful  artificial  anus. 
This  consists  in  producing  such  an  angtdation  of  the  gut  that 
it  is  impossible  for  the  feces  to  find  their  way  into  the  rectum. 


608 


DISEASES  OF  THE  RECTUM  AND  ANUS 


Unless  this  is  accomplished  and  the  bowel  is  given  absolute  rest 
from  the  passage  over  it  of  fecal  matter,  the  operation  is  a  fail- 
ure and  the  condition  of  the  patient  much  more  deplorable  than 
if  he  had  been  let  alone.  There  are  many  ways  of  procuring  a 
suitable  spur,  but  the  author  will  describe  only  those  methods 
which  have  attracted  the  most  attention  either  as  a  result  of 
their  usefulness  or  because  of  the  prominence  of  the  surgeons 
who  proposed  them. 

Herbert  W.  Allingham's  Method. — "A  good  knuckle  of  gut 
being  pulled  through  the  wound  with  the  finger  and  thumb, 
the  mesentery  is  made  out  behind  the  intestine.  A  needle 
threaded  with  carbolized  silk  is  next  passed  through  the  skin 
on  the  outer  edge  of  the  abdominal  opening,  then  through  the 
mesentery  behind  the  bowel,  back  again  through  the  mesen- 


Fig.  199. — Forming  the  Spur. 

tery,  and  is  then  tied  to  the  end  which  had  previously  gone 
through  the  skin"  (Fig.  199). 

Maydl's  Method.  —  Because  of  its  simplicity  and  effective- 
ness Maydl's  procedure  has  always  been  a  great  favorite,  and 
is  known  as  the  glass-rod  operation.  It  consists  in  passing  a 
glass  rod  through  the  mesentery  just  below  the  intestinal  loop, 
in  order  to  form  a  spur  and  prevent  the  bowel  from  falling  back 
into  the  abdomen.  The  intestine  is  then  sutured  to  the  skin 
and  the  peritoneum,  which  had  already  been  brought  up  and 
fastened. 

Weir  has  modified  Maydl's  operation  by  suturing  the  legs 
of  the  loop  together  below  the  glass  rod,  which  makes  the  spur 
more  effective. 

Kelsey's  Method  of  anchoring  the  gut  by  means  of  a  hare- 
lip-pin passed  through  the  skin,  peritoneum,  mesentery,  and 
peritoneum  and  skin  on  the  opposite  side  at  the  junction  of  the 


COLOSTOMY  609 

Upper  and  middle  thirds  of  the  incision  has  not  been  well  re- 
ceived. In  regard  to  this  procedure,  he  says :  "By  this  nrieans 
the  gut  is  so  firmly  held  in  position  that  it  cannot  be  dislodged 
by  any  vomiting,  and  a  perfectly  satisfactory  spur  is  formed, 
which  will  prevent  any  passing  of  fecal  matter  beyond  the 
opening."  Kelsey  formerly  used  a  silver  wire  passed  through 
the  abdominal  wall  on  one  side  and  out  through  the  other  side 
to  accomplish  the  same  purpose,  the  end  of  the  wire  being 
fastened  with  shot  to  hold  them  in  place. 

Mathews's  Method  as  described  by  him  is  as  follows :  "I 
pass  two  delicate,  but  stout,  steel  needles,  made  for  the  purpose, 
through  the  abdominal  integument  on  one  side  and  out  of  the 
abdominal  wall  on  the  other  side,  catching  only  enough  of  the 
true  skin  to  insure  a  smooth  surface.  These  needles  are  made 
about  five  inches  in  length,  with  a  heavy,  blunt  end  at  one  ex- 
tremity, and,  after  they  have  passed  through  in  the  manner 
described,  they  are  secured  by  drawing  the  parts  as  tightly 
as  desired,  and  then  pressing  a  bullet  upon  them  at  the  other 
■extremity  to  insure  their  remaining  in  position." 

Bodine's  Method  has  been  very  well  received,  because  it  in- 
sures the  acute  angulation  necessary  for  the  formation  of  a  per- 
fect spur.  This  surgeon,  after  drawing  the  bowel  outside  the 
abdomen,  sutures  the  afferent  and  efferent  legs  of  the  loop  to- 
gether on  the  outer  and  inner  sides  for  a  distance  of  two  or 
three  inches  (5.08  to  7.62  centimeters)  below  where  it  is  to  be 
attached  to  the  abdominal  wall.  In  this  way  the  mesentery  is 
welded  between  the  two  rows  of  suture.  When  the  protruding 
gut  is  cut  away,  the  double-barreled  shotgun-life  efTect  already 
described  is  obtained. 

Other  Methods.  —  Schinzinger,  Madelung,  Maydl,  Reclus, 
Weir,  and  the  author  have  each  performed  one  or  more  opera- 
tions by  dividing  the  sigmoid,  suturing  the  proximal  end  to  the 
inguinal  region,  closing  the  distal  end  of  the  bowel,  and  drop- 
ping the  latter  back  into  the  abdominal  cavity.  The  object  in 
each  instance  is  to  prevent  the  escape  of  even  a  small  part  of 
the  fecal  matter  into  the  diseased  bowel  below. 

The  greatest  objection  to  dropping  the  closed  end  of  the 
gut  back  into  the  belly  is  that,  when  the  bowel  is  obstructed 
below,  mucus  collects  above  the  obstruction,  causing  much 
discomfort  in  this  part  of  the  bowel. 

The  simplest,  quickest,  safest,  and  most  satisfactory  ways 


610  DISEASES  OF  THE  RECTUM  AND  ANUS 

of  making  an  effective  spur  are  by  the  Allingham  "mesenteric 
stitch"  or  the  Maydl  glass  rod. 

The  prevention  of  fecal  incontinence  following  the  establish- 
ment of  an  artificial  anus,  next  to  making  the  spur,  is  the  most 
important  feature  of  the  operation.  It  is  impossible  to  make,  in 
any  part  of  the  intestine,  an  artificial  anus  over  which  the  patient 
will  have  absolute  control.  Many  of  these  sufferers — in  fact,  the 
majority  of  them — have  control  over  solid  and  semisolid  feces, 
but  no  matter  how  hard  they  may  try  to  prevent  it,  gas  and 
fecal  matter,  when  liquid,  will  sometimes  escape  at  inopportune 
times.  Fortunately,  the  excreta,  except  during  attacks  of  diar- 
rhea, is  usually  solid,  or  nearly  so  by  the  time  it  reaches  the 
opening  in  the  left  inguinal  region,  and  because  of  this  the  in- 
voluntary discharge  of  feces  takes  place  vej-y  much  less  frequently 
than  is  generally  supposed.  A  large  majority  of  the  patients 
colostomized  by  the  author  have  not  been  annoyed  by  the  con- 
stant or  frequent  discharge  of  feces  through  the  new  anus.  On 
the  contrary,  they  usually  have  one  or  two  well-formed  motions 
daily,  and  not  a  few  of  them  have  suffered  from  constipation. 
The  author  attributes  the  good  results  obtained  in  these  cases 
to  (a)  separation  of  the  fibers  of  the  abdominal  muscle,  (b) 
the  moderately  small  anus  made,  and  (c)  more  particularly  to 
education  of  the  patient  as  to  how  and  when  the  bowel  should 
act.  When  the  muscular  fibers  are  separated  instead  of  being 
cut,  more  control  is  to  be  had  over  the  gut,  because  the  ab- 
dominal muscles  through  which  it  passes  are  largely  voluntary, 
and,  when  made  to  contract,  they  shut  the  bowel  off  partially 
or  completely  by  contracting  around  it  at  different  angles.  An 
artificial  anus  which  is  very  large  is  more  difficult  to  control  than 
one  of  medium  size,  but  the  anus  which  gives  the  most  trouble, 
in  so  far  as  fecal  incontinence  is  concerned,  is  one  in  which  the 
opening  is  so  small  that  a  strictnred  condition  is  produced.  In 
such  cases  the  feces  constantly  dribble  out,  making  life  a  burden 
to  the  patient.  It  is  the  custom  of  the  author  to  instruct  colos- 
tomized patients  to  have  two  actions  daily,  one  immediately 
after  breakfast  and  one  before  retiring.  This  is  done  by  throw- 
ing a  small  quantity  of  water  into  the  descending  colon  to  start 
up  peristalsis;  in  the  majority  of  instances,  a  solid  movement 
is  secured  in  a  very  short  time. 

Large  quantities  of  water  are  contra-indicated  because  the 
water  liquefies  the  feces,  and  is  discharged  frequently  and  in 


COLOSTOMY  611 

small  quantities.  Furthermore  it  requires  a  considerable  time 
to  come  away,  because  it  collects  in  the  transverse  and  descend- 
ino-  colon.  The  smaller  amount  acts  as  a  stimulant  and  causes 
the  bowel  completely  to  empty  itself  at  one  time. 

It  usually  requires  but  a  few  weeks  to  educate  the  bowel  to 
wait  for  the  injections;  just  the  same  as  is  done  by  the  rectum, 
in  persons  suffering  from  chronic  constipation,  who  have  been 
in  the  habit  of  securing  a  stool  by  means  of  enemata. 

No  attempt  is  made  to  control  the  number  and  consistence 
of  the  stools  for  the  first  fezv  days  after  the  anus  has  been  made, 
for  the  reason  that  there  is  usually  a  large  accumulation  of  feces 
in  the  colon ;  in  addition,  the  bowel  is  in  an  irritable  state,  and 
it  would  be  absolutely  useless  to  attempt  to  stop  the  frequent 
fecal  evacuations. 

During  the  past  few  years  several  methods  of  dealing  with 
the  bowel  in  performing  left  inguinal  colostomy  have  been  sug- 
gested, all  of  which  have  for  their  object  the  lessening  or  pre- 
vention of  fecal  incontinence  following  the  operation.  Of 
these,  the  following  are  the  most  widely  known : — 

Bailey's  Method  consists  in  bringing  the  bowel  out  through 
the  usual  site  in  the  inguinal  region,  and  suturing  the  intestine 
to  the  surrounding  musculature.  A  second  incision  slightly 
over  an  inch  (2.54  centimeters)  in  length  is  then  made  down  to 
and  exposing  the  external  oblique  muscle,  two  inches  (5.08 
centimeters)  below  the  first.  The  remaining  steps  of  the  opera- 
tion are  described  by  Bailey  as  follows :  "The  band  of  skin  and 
subcutaneous  tissue  between  the  two  incisions  was  next  freed 
from  the  subjacent  structures  with  the  handle  of  the  scalpel, 
and  the  loop  of  the  intestine  drawn  out  through  the  lower 
wound,  where  it  was  subsequently  kept  in  position  by  a  glass 
rod  passed  through  the  mesentery.  The  upper  skin  wound  was 
closed.  The  object  of  the  operation  as  described  was  to  allow 
the  pad  to  make  pressure  upon  a  portion  of  the  length  of  the 
wall  of  the  viscus,  as  well  as  upon  the  opening  itself,  and  thus 
obtain  more  efficient  control,  as  in  Franck's  method  of  perform- 
ing gastrostomy." 

Weir's  Method  is  a  combination  of  the  operations  of  Schin- 
zinger, — who  divides  the  sigmoid  and  sutures  the  proximal  end 
of  the  gut  to  the  abdominal  incision,  after  the  distal  end  has 
been  closed  and  dropped  back  into  the  abdomen, — and  of 
"Witzel,  who  carries  the  intestinal  loop  downward  and  outward 


613  DISEASES  OF  THE  RECTUM  AND  ANUS 

beneath  the  skin,  where  it  is  brought  out  through  a  second  in- 
cision made  at  a  point  two  inches  below  the  crest  of  the  ihum. 
Weir  describes  his  operation  as  fohows :  "The  intestine  is 
made  to  come  out  through  the  usual  opening  inside  the  crest 
of  the  ihum ;  the  lower  end  is  cut  off,  inverted,  sewed  together, 
and  dropped  back  into  the  abdominal  cavity,"  .  .  .  "or  it 
may  be  retained  in  the  original  wound.  The  upper  end,  duly 
contracted  by  a  ligature  and  disinfected  or  sutured  together,  is 
then  drawn  through  a  canal  formed  for  it  by  separating  one 
layer  of  the  abdominal  muscle  from  the  other  up  to  the  outer 
edge  of  the  ilium,  where  it  may  be  necessary  to  divide  the  lim- 
iting fascia,  so  that  the  intestine  can  be  brought  out  through 
the  skin  incision  an  inch  long  (2.54  centimeters)  previously 
made  outside  the  pelvis.  This  opening  was,  in  my  cases,  situ- 
ated one  to  two  inches  (2.54  to  5.08  centimeters)  below  and  one 
inch  (2.54  centimeters)  behind  the  anterior  superior  spine.  The 
first,  or  abdominal,  incision  is  now  sutured,  and  a  few  stitches 
secures  the  bowel  to  the  iliac  skin  opening." 

Bernays's  Method  has  for  its  object  the  formation  of  a  pouch 
above  the  artificial  anus  in  which  the  feces  accumulate  and  re- 
main until  they  become  solid  instead  of  rushing  down  upon  the 
opening  at  any  time.  This  is  done  by  making  a  spur  one  and 
one-fourth  to  one  and  one-half  inches  (3.17  to  3.81  centimeters) 
above  the  site  of  the  new  anus,  as  follows :  "By  means  of  a 
double  line  of  sero-muscular  sutures  across  the  gut,  a  spur  pro- 
jecting one-half  inch  (1.27  centimeters)  in  the  gut  at  its  middle 
can  be  established.  The  first  line  of  sutures  should  consist  of 
six  sutures  one-eighth  of  an  inch  (0.3  centimeters)  apart  and 
including  one-half  inch  (1.27  centimeters)  of  the  serosa  and 
musculosa  parallel  to  the  long  axis  of  the  gut.  The  second  line 
should  consist  of  ten  sutures  one-eighth  of  an  inch  (0.3  centi- 
meters) apart,  completely  burying  the  first  line.  The  spur  must 
be  so  made  on  the  side  opposite  the  mesenteric  attachments 
that  it  points  toivard  the  mesenteric  tenia.'"  Bernays  has  per- 
formed this  operation  in  but  two  instances,  and  says  it  appears 
to  serve  its  purpose  admirably. 

This  surgeon  has  also  suggested  that  incontinence  might 
be  averted  by  dividing  the  sigmoid,  stripping  the  mucosa  from 
the  musculature  of  the  proximal  end  for  a  distance  of  one-half 
inch  (1.27  centimeters)  or  more ;  the  two  outer  coats  of  the 
intestine  are  then  rolled  inward  and  made  to  curl  up,  forming 


COLOSTOMY 


613 


a  circular  muscular  spur  or  sphincter,  after  which  the  mucosa 
is  sutured  to  the  skin.  This  latter  procedure  has  been  per- 
formed but  once,  and  then  upon  a  dog.  The  operation  was 
tedious,  and  its  originator  has  but  httle  faith  in  the  method. 

"Wyeth's  Method  consists  in  drawing  the  sigmoid  up  through 
the  wound  until  the  rectal  end  is  made  taut,  the  excess  of  gut 
being  returned  into  the  abdomen  above  the  opening.  The  legs 
of  the  loop  are  sutured  after  Bodine's  method,  and  the  bowel 
is  supported  by  a  glass  rod  or  transverse  sutures  placed  be- 
neath the  intestine.     The  object  of  Wyeth's  operation,  as  he 


Fig.  200.— Double  Procidentia  Following  Left  Inguinal  Colostomy  where  the 
Excess  of  the  Intestine  and  Mesentery  were  not  Amputated  During  the 
Operation. 

puts  it,  is  to  a  form  an  artificial  sigmoid  or  storcJwuse  capable  of 
holding  a  large  amount  of  fecal  matter  which  may  be  dis- 
charged at  long  intervals,  thus  preventing  frequent  soiling  of 
the  dressings. 

Gersuny's  Method  of  preventing  fecal  incontinence  has  been 
fully  described  in  the  preceding  chaper,  and  consists  in  twisting 
the  bowel  upon  its  long  axis  before  it  is  sutured  to  the  skin. 

Other  Methods. — Braune  closes  the  rectal  end  of  the  bowel 
and  drops  it  back  into  the  abdomen.  The  proximal  end  is  then 
carried  downward  beneath  the  skin  and  brought  out  throuo-h  a 


614 


DISEASES  OF  THE  RECTUM  AND  ANUS 


second  incision  in  the  anterior  surface  of  the  thigh,  where  it  is 
anchored. 

Von  Hacker,  Witzel,  Weir,  House,  Maydl,  Franck,  Tuttle, 
and  the  author  have  had  more  or  less  success  in  lessening  in- 
continence by  bringing  the  sigmoid  out  through  the  separated 
fibers  of  the  left  rectus  muscle ;  or  by  splitting  the  rectus  ab- 
dominis and  carrying  the  gut  through  the  muscle  (from  right 
to  left  [Witzel]  or  left  to  right  [von  Hacker])  between  its 
anterior  and  posterior  fibers,  when  it  is  brought  and  sutured 
to  the  skin  around  a  second  incision  made  for  the  purpose. 

The  author  has  on  several  occasions  made  a  preliminary 


Fig.  201. — Showing  how  Procidentia  Takes  Place  Through  an  Artificial  Anus 
when  the  Mesentery  is  Lett  Long  as  in  Fig.  203. 


vertical  incision  about  three  inches  (7.62  centimeters)  to  the  left 
of  the  median  line  (Fig.  184,  B),  separated  the  external  oblique 
from  the  internal,  pushed  the  bowel  between  them  for  some  dis- 
tance, and  brought  it  out  and  anchored  it  in  the  usual  location 
of  a  left  inguinal  anus.  He  has  also  carried  the  muscle  to  the 
left,  between  the  external  oblique  muscle  and  skin,  and  also  be- 
tween the  internal  oblique  and  the  transversalis  abdominis.  He 
has  noticed  but  little,  if  any,  difference  in  the  results  obtained 
from  the  different  procedures.  Furthermore,  the  results  fol- 
lowing Bailey's  operation  and  those  following  Witzel's  method, 
in  which  the  gut  is  carried  under  the  skin  and  brought  out 
behind  the  crest  of  the  ilium,  have  not,  in  the  author's  hands 


COLOSTOMY 


615 


been  entirely  satisfactory.  Absolute  continence  cannot  be  pro- 
duced by  any  of  these  methods.  They  serve  to  diminish  leak- 
age, however,  by  allowing  pressure  to  be  made  both  upon  a 
section  of  the  bowel  beneath  the  skin  and  over  the  opening. 
The  compression  can  be  made  by  means  of  a  pad  of  gauze, 
supported  by  a  bandage,  or  by  any  one  of  the  many  trusses 
devised  for  the  purpose. 

One  of  the  best  appliances  used  by  the  author's  patients  has 
been  a  dumb-bell-like  apparatus,  consisting  of  two  small  rubber 
balls  joined  by  a  neck;  one  of  these  bulbs  is  placed  in  the 
lower  end  of  the  descending  colon  and  the  other  left  to  the  out- 


Fig.  202.— Appearance  of  the  Intestine  where  the  Excess  of  Both  Bowel 
and  Mesentery  has  been  Removed  to  Prevent  Procidentia. 

side ;  they  are  now  inflated  by  means  of  a  connecting  tube, 
and  as  a  result  the  abdominal  wall  is  clamped  between  the  two 
balls  and  the  feces  are  effectively  retained  until  they  are  re- 
moved. The  only  objection  to  this  is  the  slight  inconvenience 
caused  by  pressure. 


COMPLICATIONS   AND   SEQUELS 

The  complications  following  colostomy  operations  are  few, 
and  rarely  cause  serious  trouble  when  the  operation  has  been 
properly  performed.  The  most  frequent  complications  are 
stricture  and  procidentia.  A  strictured  condition  of  the  new  anus 
may  result  from  the  opening  having  been  made  too  small  at 
first,  or  it  may  be  caused  by  undue  contraction  following  the 


616 


DISEASES  OF  THE  RECTUM  AND  ANUS 


formation  of  large  scars,  the  latter  condition  being  a  frequent 
sequel  of  the  operation  when  made  upon  negroes  or  dark- 
skinned  individuals.  In  most  cases  the  contraction  occuis 
slowly,  and  does  not  cause  much  annoyance  for  several  months, 
at  which  time  the  opening  becomes  so  small  that  the  solid  feces 
are  retained  and  the  liquid  constantly  dribbles  through  the 
opening.  In  such  cases  the  opening  should  be  stretched  with 
the  finger  or  bougie,  or  enlarged  to  the  desired  size  by  one  or 
more  incisions.  In  extreme  cases  it  may  be  necessary  to  detach 
the  bowel  and  move  the  anus  to  some  other  point. 

Prolapse   of  the   bowel   through   an   artificial   anus   (Figs. 


Fig.  203.— Showing  Appearance  of  the  Gut  with  its  Excess  of  Mesentery  which 
was  not  Removed  During  the  Operation  of  Left  Inguinal  Colostomy,  and 
which  Permits  the  Bowel  to  Protrude  from  Slight  Straining. 


200  and  201  and  Plate  XXXVII)  is  seldom  encountered  in 
cases  in  which  the  viscus  was  made  taut  from  both  above  and 
below  the  opening  before  being  stitched  to  the  abdomen  and 
afterward  amputated  (Fig.  202).  In  those  instances,  however, 
in  which  the  mesentery  is  long  and  the  excess  of  gut  is  not 
removed,  procidentia  is  to  be  anticipated  (Figs.  201  and  203). 
The  prolapse  may  be  single  and  the  protruding  gut  be  either  the 
descending  colon  or  the  sigmoid  and  rectum ;  or  it  may  be 
double  and  include  both  (Fig.  200  and  Plate  XXXVII).  There 
may  be  but  a  slight  eversion  of  mucous  membrane  or  the  bowel 
may  protrude  for  several  inches.  The  author  has  seen  one  case 
in  which  sixteen  inches  of  the  gut  (40.64  centimeters)  pro- 


iif 


.^ 


PLATE   XXXVII.— CASE    OF   DOUBLE  PROCIDENTIA  OF    PART 

OF  DESCENDING  COLON   AND   RECTUM    THROUGH 

ARTIFICIAL    ANUS. 


COLOSTOMY  G17 

jected  through  the  upper  opening.  When  the  intestine  cannot 
be  prevented  from  prolapsing  by  astringent  appHcations  and 
irrigations  or  by  Hnear  cauterization,  the  abdomen  should  be 
opened  and  a  sufficient  amount  of  one  or  both  ends  of  the  gut 
amputated  and  the  remaining  ends  sutured  to  the  skin. 

Another  rare  complication  following  colostomy  operations 
is  that  in  which  tJie  bozvel  appears  to  move  from  tlie  loiver,  or 
rectal,  opening  instead  of  from  the  descending  colon,  or  upper  open- 
ing. This  is  a  matter  of  little  consequence,  however,  and  is 
caused  by  twisting  of  the  bowel  as  it  was  hooked  up  by  the 
finger  and  brought  out  through  the  wound. 

When  the  skin  surrounding  the  artificial  anus  becomes 
excoriated  from  an  irritating  discharge,  whether  from  the  bowel, 
ulcers  about  the  margin  of  the  wound,  or  from  a  stitch-abscess, 
the  parts  should  be  cleansed  frequently  and  dusted  over  with 
talcum  powder  before  the  dressings  are  applied.  Every  effort 
should  be  made  to  stop  the  discharge  as  soon  as  possible. 


LITERATURE  ON  COLOSTOMY    (COLOTOMY,  ARTIFICIAL  ANUS) 


Allingham  (H.  W.) :    "Colostomy,"  etc.,  Brit.  Med.  Jour.,  i,  p.  1013,  1892. 

"Colostomy/'   Gant's  "Diseases  of  the  Rectum  and  Anus,"  p.  308, 

1896. 
Andry:    "Un  nouveau  proeede  de  colostomie  iliaque,"  etc.,  Archives  Prov.  de 

Chir.,  i,  p.  347,  1892. 
Bailey:    "Colostomy,  Modification  of,"  B7-it.  Med.  Jour.,  i,  p.  441,  1900. 
Ball:    "Laparo-  and  Lumbo-  Colotomy,  Contrast  Between,"  Trans.  Acad.  Med. 

Ireland,  v,  p.  178,  1887. 
Baracz:    "Enterectomy,"  etc.,  CentfalM.  f.  CMr.,  No.  27,  p.  67,  1894. 
Batt:    "Colostomy,  Statistics  of,"  etc.,  Amer.  Jour.  Med.  Sci.,  Oct.,  p.  423,  1884. 
Bell:    "Preliminary  Colostomy,"  etc.,  Mathews's  Med.  Quart.,  v,  p.  66,  1898. 
Bernays:    "Sphincteropoesis,"  Mathews's  Med.  Quart.,  i,  p.  66,  1894. 
Bodenhamer:    "Lumbar  Colotomy,"  etc.,  N.  Y.  Med.  Jour.,  liv,  p.  212,  1891. 
Bodine:    "Inguinal  Colostomy,"  etc.,  Mathews's  Med.  Quart.,  iv,  p.  168,  1897. 
Briddon:    "Laparo-Colotomy,"  N.  7.  Med.  Jour.,  lii,  p.  310,  1890. 
Bryant:    "Colotomy,"  "Practice  of  Surgery,"  p.  511,  1885. 

"Colotomy,  Bradshaw  Lectures  on,"  "Wood's  Med.  and  Surg.  Monog.,'* 

vii,  p.  199,  1890. 
Bryant   (J.  D.) :    "Operative  Surgery,"  ii,  pp.  675-702,  1901. 
Cripps:     "Inguinal  Colostomy,  Operation  for,"  etc.,  Brit.  Med.  Jour.,  Oct.  6, 

1888. 
Dennis:     "Colostomy,"  "System  of  Surgery,"  iv,  p.  494,  1896. 
Dixon:    "Inguinal  Colotomy,"  etc.,  Atlanta  Med.  and  Surg.  Jour.,  vii,  p.  660, 

1891. 
Dumgil:    "De  la  Colotomie."  etc.,  i,  p.  542,  1886. 


618-  DISEASES  OF  THE  RECTUM  AND  ANUS 

Edebohls:    "The  Kraske  Operation  in  Women,"  etc.,  Amer.  Jour.  Obstet.,  xliv, 

No.  2,  p.  162,  1901. 
Gangolphe:    "Colostomie  Iliaque,"  etc.,  Rev.  de  Chir.,  xxi,  p.  179,  1900. 
Gant:    "Left  Inguinal  and  Lumbar  Colostomy,  History  of,"  Post-graduate,  xvi, 

p.  738,  1901. 
Hacker:    "Colotomy,"  etc.,  Beitrdge  z.  klin.  Chir.,  xxiii,  p.  628,  1899. 
Hartmann:    "Rectal  Cancer,  Colostomy  for,"  etc..  Revue  de  Chir.,  Paris,  Nov. 

10,  1900. 
Hochenegg   (by  Lorenz) :    "Radical  Operation  for  Rectal  Cancer,"  etc.,  ArcMv 

f.  klin.  Chir.,  Ixiii,  p.  854,  1901. 
Howse:    "Colostomy,"  etc.,  Holmes's  "System  of  Surgery,"  i,  p.  801,  1883. 
Jaennel:    "De  la  Colostomie,"  etc.,  Midi  Med.,  ii,  p.  580,  1893. 
Jesset:    "Inguinal  Colostomy,"  etc.,  Brit.  Med.  Jour.,  1889. 
Jones:    "Colostomy,  Modifications  of,"  Brit.  Med.  Jour.,  i,  p.  117,  1892. 
Kelsey:    "Colotomy,  Improved  Technique,"  etc.,  N.  Y.  Med.  Jour.,  xxxvi,  p.  398, 

1889. 

"Choice  between  Excision  and  Colostomy  for  Rectal  Cancer,"  IV".  Y, 

Med.  Jour.,  Ivi,  p.  538,  1892. 
Kumel:    "Transplantation  of  Colon,"  etc.,  Archives  of  Chir.,  lix,  p.  555,  1899. 
Lange:    "Inguinal  Colotomy,"  Amer.  Surg.,  v,  p.  491,  1887. 
Mathews:    "Colotomy,"  "Diseases  of  Rectum  and  Anus,"  p.  401,  1896. 
Maydl:    "Zur  Technik  der  Kolotomie,"  Centralbl.  f.  Chir.,  No.  24,  1888. 
Maylard:     "Colotomy,  Operation  of,"  "Surgery  of  the  Alimentary  Canal,"  p. 

544,  1896. 
Mayo:    "Colostomy,"  etc.,  Amer.  Med.,  1,  p.  120,  1901. 
Mills:    "Roberts's  Contribution  to  Inguinal  Colotomy,"  Brit.  Med.  Jour.,  i,  p. 

385,  1892. 
Paget:    "Colotomy,"  etc.,  Lancet  (London),  i,  p.  835,  1870. 
Paul:    "Method  of  Performing  Inguinal  Colotomy,"  Brit.  Med.  Jour.,  ii,  p.  118, 

1891. 

"Colectomy,"  B7it.  Med.  Jour.,  i,  pp.  11,  39,  1895. 
Pennington:    "Colotomy,"  etc..  Jour.  Amer.  Med.  Assoc,  xxi,  p.  723,  1893. 
Pozzi:    "Colostomie,"  etc.,  France  Med.,  xxvii,  p.  57,  1880. 
Purcell:    "Malignant  Disease  of  Rectum,  Colotomy  for,"  Lancet   (London),  ii, 

p.  nil,  1889. 

"Colostomy,  New  Method,"  Illinois  Med.  News,  v,  p.  271,  1889. 
Quenu  et  Hartmann:     "Colostomie,"  "Chirurgie  du  Rectum,"   1889. 
Reeves:    "Sigmoidostomy  Simplified,"  Brit.  Med.  Jour.,  i,  p.  67,  1892. 
Robson:    "Inguinal  Colostomy,  Modification  of,"  Brit.  Med.  Jour.,  i,  p.  66,  1892. 
Rose:    "Early  Colotomy,"  Practitioner,  vi,  p.  11,  1897. 
Roux:    "Colostomie,"  etc..  Revue  Med.  de  la  Suise,  1898. 
Smith   (Greig)  :    "Colostomy,"  etc..  Lancet  (London),  July  23,  1898. 
Tuttle:     "Temporary  Inguinal  Anus,"  paper  read   before  the  American  Proc- 
tologic Society  at  Washington,  1900. 
Weir:    "High-Seated  Rectal  Cancer,"  etc.,  Jour.  Amer.  Med.  Assoc,  xxxvii,  p. 

13,  1901. 

"Formation  of  an  Artificial  Anus,"  etc.,  A^.  Y.  Med.  Record,  Ivii,  p. 

661,  1900. 
Wyeth:    "Colostomy,"  etc.,  Jour.  Amer.  Med.  Assoc,  xxxv,  p.  1458,  1900. 


CHAPTER  XXXV 

CLOSURE  OF  ARTIFICIAL  ANUS  AND   FECAL  FISTULA 

The  present  chapter  will  be  devoted  to  the  discussion  of 
the  more  simple  and  effective  methods  of  closing  an  artificial 
anus  and  those  forms  of  fecal  fistulse  which  resemble  this  con- 
dition in  location  and  character.  Before  giving  the  treatment 
of  these  two  conditions  it  is  necessary  to  differentiate  one  from 
the  other,  so  that  the  methods  suggested  for  their  relief  may 
be  more  easily  understood. 

An  artificial  anus  is  a  communication  established  between 
some  part  of  the  large  or  small  intestine  and  the  surface  of  the 
body  through  which  all  the  feces  are  discharged  (Figs.  194  and 
197  and  Plate  XXXVI).  Such  an  opening  is  nearly  alzvays 
made  intentionally  by  the  surgeon  to  relieve  obstruction  or 
some  diseased  condition  of  the  bowel  from  which  it  is  desirable 
to  remove  the  irritation  caused  by  the  feces.  It  is  usually  made 
in  some  part  of  the  colon,  the  most  frequent  site  being  in  the 
left  iliac  region,  where  the  sigmoid  is  opened  for  the  relief  of 
stricture,  malignant  disease,  or  obstinate  ulceration  of  the 
rectum,  membranous  colo-proctitis,  proliferating  (vegetating) 
proctitis,  etc. 

A  fecal  fistula  consists  of  a  sinus,  superficial  or  deep,  ex- 
tending from  the  intestine  to  the  body-surface,  through  which 
but  a  part  of  the  feces,  usually  the  liquid  portion,  is  discharged, 
while  the  remainder  passes  on  to  be  evacuated  through  the 
normal  channel.  In  very  rare  cases  in  which  the  destruction 
of  the  bowel-wall  has  been  extensive  and  the  fistulous  opening 
is  large,  all  the  fecal  matter  may  be  discharged  through  the 
fistula.  It  is  usually  formed  accidentally  as  a  result  of  direct 
violence,  penetrating  and  gunshot  wounds,  and  in  surgical  op- 
erations in  which  the  intestine  has  been  injured  by  the  knife 
or  by  separation  of  adhesions,  or  extensive  sloughing  follows. 
Again,  it  may  be  caused  by  deep-seated  abscesses  of  the  pelvis 
or  abdomen,  strangulated  hernia  or  other  intestinal  obstruc- 
tion, perforating  benign  or  malignant  ulceration,  etc. 

A  fecal  fistula  is  frequently  the  result  of  an  attempt  to  estab- 
lish an  artificial  anus.     The  author  has  had  manv  such  cases 

^  (619) 


620 


DISEASES  OF  THE  RECTUM  AND  ANUS 


referred  to  him  for  treatment.  In  these  cases  the  operator  had 
failed  to  accompHsh  his  purpose,  because  the  intestine  was  sim- 
ply brought  up  and  sutured  to  the  skin  or  to  the  inner  abdom- 
inal wall,  no  provision  being  made  for  a  spur;  after  the  opening 
had  been  made  in  the  bowel  the  feces  were  discharged  through 
both  the  rectum  and  the  abdominal  opening  (Fig.  193).  Such 
an  accident  is  easily  avoided  by  forming  a  proper  spur  (Fig, 
194) ;  so  that,  when  the  knuckle  of  gut  external  to  the  abdom- 
inal wall  is  cut  away,  the  legs  of  the  loop  remam  parallel,  making  it 
impossible  for  the  feces  to  pass  into  the  bowel  below.  A  colos- 
tomy opening  thus  made  has  the  typic  double-barreled  shotgun 
appearance  (Fig.  197  and  Plate  XXXVI).  This  operation  is 
described  in  detail  in  the  chapter  on  colostomy. 


Fig.  204. 


-Clamp  Used  in  Gant's  Operation  for  the  Closure  of  an 
Artificial  Anus  (Exact  Size). 


METHODS  OF  CLOSING  AN  ARTIFICIAL  ANUS 

Closure  of  an  artificial  anus  where  the  serous  surfaces  of  the 
legs  of  the  loop  of  the  intestine  have  grown  together  forming 
a  spur  is  much  more  difficult  than  that  of  a  simple  fecal  fistula, 
because  the  bridge  of  tissue  formed  by  the  adherent  legs  of  the 
original  intestinal  loop  and  mucosa  covering  them  must  be 
destroyed  before  continuity  of  the  intestine  can  be  restored 
(Figs.  194,  197,  and  205).     An  artificial  anus  may  be  closed  by 

(1)  clamping  the  spur  and  destroying  it  by  pressure-necrosis, 

(2)  by  resection  and  anastomosis,  or  (3)  by  ligation. 

Clamping  the  Spur. — Dupuytren  was  the  first  surgeon  to 
suggest  destruction  of  the  spur  by  clamping.  For  this  purpose 
he  devised  a  special  clamp  known  as  the  entcrotoinc.  This  instru- 
ment was  later  modified  by  Gross.    Dupuytren  first  successfully 


CLOSURE  OF  ARTIFICIAL  ANUS  AND  FECAL  FISTULA 


621 


accomplished  the  closure  of  an  artificial  anus  by  means  of  his 
enterotome  in  1815,  and  in  1828,  before  the  French  Academy  of 
Medicine,  he  reported  41  cases  treated  by  his  method.  In  29  of 
these  cases  a  complete  cure  was  effected,  while  in  9  a  fistula 
persisted,  and  3  patients  died  from  the  operation. 

Gant's  Clamp  Operation.  —  The  Dupuytren  and  Gross  en- 
terotomes  and  other  clamp-forceps  used  for  destroying  the  spur 
are  heavy  and  cumbersome,  and  project  from  the  abdomen, 
rendering  it  difficult  to  apply  dressings  and  causing  the  patient 
great  annoyance.  In  order  to  avoid  these  objectionable  feat- 
ures  of  these  instruments,   the   author  has   devised   a   special 


Fig. 


205. — Manner  of  Applying   Clamp   in   Gant's   Operation   for   the 
Closure   of   an   Artificial   Anus. 


fenestrated  clamp  (Figs.  204,  205,  and  206  and  Plate  X),  which 
is  similar  in  every  respect  to  his  fenestrated  ''valve'' -clamp 
except  that  it  is  larger.  The  weight  of  this  instrument  is  imper- 
ceptible to  the  patient,  and  when  in  place  the  shank,  which  is 
bent  at  an  angle  to  the  clamp,  lies  Hat  upon  the  abdomen.  The 
jaws  of  the  clamp  are  fenestrated,  one-half  inch  (1.27  centi- 
meters) broad,  and  one  and  one-fourth  inches  (3.18  centi- 
meters) or  more  in  length.  It  is  applied  by  means  of  Gant's 
clamp-appHcator  or  forceps,  as  follows :  It  is  placed  in  the 
applicator  or  strong  angular  pressure-forceps  and  so  adjusted 
that  its  jaws  are  open  to  the  fullest  extent.  The  parts 
having  been  thoroughly  cleansed,  the  spur  is  carefully  stripped 


622 


DISEASES  OF  THE  EECTUM  AND  ANUS 


with  the  fingers  in  order  to  remove  any  coil  of  the  small 
intestine  which  may  be  included  in  its  angle.  The  clamp 
is  then  applied,  one  blade  in  each  opening  (Fig.  205),  and 
pushed  down  sufficiently  to  include  the  entire  spur  (Fig.  206), 
when  it  is  released  from  the  instrument.  It  is  allowed  to  remain 
w  situ  until  it  comes  away  unaided,  which  is  usually  after  six 
to  nine  days,  depending  upon  the  amount  and  character  of  the 
tissue  to  be  removed.  The  clamp  causes  slight  soreness,  but  no 
acute  pain.  To  avoid  complications,  the  patient  must  remain 
quietly  in  bed  until  it  sloughs  out.  When  the  spur  has  been 
successfully  destroyed,  the  skin  and  edges  of  the  opening 
should  be  freshened  and  closed  with  catgut  or  silk  sutures 
(Fig.  207).  When  there  is  considerable  tension,  the  parts 
should   be    drawn   together   and    supported   by   well-adjusted 


Fig.  206. — Gant's  Clamp  in  Position  in  Operation  for  Closure  of 
an  Artificial  Anus. 


adhesive  straps.  The  author  has  performed  this  operation  in 
two  cases,  and  both  were  successful. 

Resection  and  Anastomosis. — The  clamping  operation  is  pref- 
erable, but  when  for  any  reason  it  is  contra-indicated  the  most 
satisfactory  manner  of  closing  the  artificial  anus  is  to  re-estab- 
lish the  normal  channel  by  resection  and  anastomosis. 

The  technic  of  this  operation  is  as  follows :  After  the  parts 
have  been  cleansed  and  the  opening  in  the  bowel  closed  with 
continuous  catgut  suture  to  prevent  the  feces  from  soiling  the 
wound,  the  skin  about  the  opening  is  divided  by  semicircular 
incisions  and  the  gut  carefully  dissected  from  its  attachments 
and  brought  well  up  through  the  incision.  That  portion  of 
the  bowel  included  in  the  spur  is  then  excised,  and  a  lateral  or 
end-to-end  anastomosis  made  by  means  of  the  Murphy  button, 
circular  enterorrhaphy,  or  any  of  the  various  devices  used  for 


CLOSURE  OF  ARTIFICIAL  ANUS  AND  FECAL  FISTULA 


623 


this  purpose.     The  writer  has  obtained  the  best  results  where 
the  Murphy  button  has  been  used. 

Ligature  Operation. — Another  method  suggested  for  di- 
viding the  spur  is  the  silk  ligature.  This  has  not  met  with 
favor,  because  the  spur  is  simply  divided  and  no  tissue  removed. 
The  ligature  is  introduced  through  the  spur  as  deeply  as  is  safe 
by  means  of  a  needle ;  it  is  then  tied  and  allowed  to  slough  out. 
The  writer  would  suggest  that,  if  a  ligature  is  used  at  all,  it 
should  be  of  India  rubber  and  adjusted,  tightened,  and  secured 
by  means  of  a  perforated  shot;  this  is  preferable,  because  silk  is 
but  slightly  elastic,  and  sometimes  fails  to  cut  its  way  out.    The 


Fig.  207. — Manner  of  Closing  External  Opening  After  the  Spur  has  been  Divided 
in  Gant's  Operation  for  the  Closure  of  an  Artificial  Anus. 

ligature  having  sloughed  out,  the  operation  is  completed  by 
closing  the  opening  in  the  same  manner  as  in  the  clamping 
operation. 


METHODS  OF  CLOSING  FECAL  FISTULA 

The  manner  of  closing  a  fecal  fistula  depends  largely  upon 
the  length  of  the  sinus  and  size  of  the  opening.  When  the  gut 
simply  adheres  to  the  abdominal  wall,  or  the  sinus  is  short 
and  the  feces  are  discharged  through  a  small  opening,  it  can 
often  be  cured  by  keeping  the  patient  in  the  recumbent  posi- 
tion, regulating  the  diet  so  that  the  stools  are  solid  or  semi- 


624  DISEASES  OF  THE  RECTUM  AND  ANUS 

solid  in  consistence,  and  cauterizing  the  edges  of  the  opening 
and  the  sinus  with  the  Paquehn  cautery,  silver  nitrate,  or 
copper  sulphate ;  in  addition,  a  piece  of  gauze  should  be  kept 
in  the  wound  to  act  as  a  drain  and  stimulate  healing. 

When  the  sinus  is  deep  and  tortuous,  it  should  be  care- 
fully dissected  out  and  the  opening  in  the  bowel  closed  by 
Czerny-Lembert  sutures;  the  intestine  is  then  dropped  back 
into  the  abdominal  cavity  and  the  external  wound  closed. 

When  the  opening  in  the  bowel  is  large  after  the  sinus  has 
been  dissected  out,  it  may  be  closed  by  excising  a  portion  of 
the  gut  and  making  an  end-to-end  or  lateral  anastomosis,  or 
folding  the  edges  of  the  opening  together  (adosseinent)  and 
uniting  them  with  sutures. 


LITERATURE  ON  THE  CLOSURE  OF  ARTIFICIAL  ANUS  AND 
FECAL  FISTULA 


Dennis:    "Persistent  Fecal  Fistula,"  "System  of  Surgery,"  vol.  iv,  pp.  439-449, 

1896. 
Dupuytren:  "Closure  of  Artificial  Anus,"  "Legons  ovales  de  Clin.  Chir.,"  Paris, 

1839. 
Gant:     "Artificial   Anus    and   Fecal   Fistula,"    "Diseases   of   the   Rectum    and 

Anus,"  p.  359,  1896. 
Heiman:    Dei(t.  med.  IFoe/i.,  No.  7,  1883. 
Maylard:     "Closure   of   Fecal   Fistula   and    Artificial    Anus,"   "Surgery    of   the 

Alimentary  Canal,"  p.  55-5,  1896. 
McGill:    "Closure  of  Fecal  Fistula  by  Lembert  Sutures,"  Lancet  (London),  vol. 

i.  p.  121,  1888. 


CHAPTER  XXXVI 

NEURALGIA  (NERVE-ACHE)  A^D  HYPERESTHESIA 

Obscure  continuous  or  periodic  pains  of  an  aching, 
lancinating,  or  throbbing  character  occurring  in  the  rectum 
in  neurotic  subjects  manifesting  no  discoverable  structural 
change  are  called  neuralgic. 

Rectal  neuralgia  is  a  topic  rarely  discussed  in  medical 
societies,  periodicals,  and  text-books.  The  author  has,  never- 
theless, treated  a  sufficient  number  of  patients  suffering  from 
obscure  rectal  pains  of  a  neuralgic  character  to  convince  him 
that  the  frequency  of  this  affection  is  very  much  underesti- 
mated. 

Many  physicians  contend  that  there  is  no  such  thing  as 
neuralgia  of  the  rectum.  If  this  is  so,  then  patients  do  not  suffer 
from  neuralgia  in  other  parts,  for  the  rectum  and  anus  are 
quite  as  generously  supplied  with  sensory  nerves  as  are  other 
organs  which  are  frequently  the  seat  of  neuralgic  pains. 

Women  suffer  from  rectal  neuralgia  more  frequently  than 
men,  and  it  is  a  condition  seldom,  if  ever,  encountered  in  child- 
hood. 

ETIOLOGY   AND   PATHOLOGY 

As  in  other  parts  of  the  body,  neuralgia  of  the  rectum  is 
usually  caused  by  pressure,  irritation,  or  functional  disturbance 
of  a  nerve  or  of  its  center,  or  to  a  neuritis.  The  author  treated 
a  gentleman  suffering  from  alcoholic  neuritis  who  complained 
of  intense  pam  in  his  rectum.  Under  systemic  treatment  he 
gradually  recovered  from  the  neuritis,  and  as  this  occurred  the 
pain  in  the  rectum  disappeared. 

Neuralgia  is  often  produced  or  aggravated  by  anemia, 
especially  in  women,  because  of  menorrhagia  and  the  loss  of 
blood  during  labor. 

Constipation  and  fecal  impaction  are  causative  factors  for 
two  reasons :  (a)  because  of  pressure  on  the  nerves  by  the  fecal 
mass ;  (b)  the  rectum  at  all  times  contains  a  multiplicity  of 
micro-organisms  having  pathogenic  powers  which  are  active 
in  producing  putrefaction.  It  is  not  improbable  that  when  the 
feces  are  retained  for  a  long  time  there  is  produced,  by  the 

40  (625) 


626  DISEASES  OF  THE  RECTUM  AND  ANUS 

activity  of  these  bacteria,  a  decisive  poison,  which,  by  its  irri- 
tating quahties,  causes  neuralgia  in  this  region.  It  may  be 
that  the  poison  produces  these  pains  by  acting  directly  upon 
the  peripheral  nerve-endings,  or  they  may  be  secondary  to 
disturbance  of  the  nerve-centers  caused  by  the  poison  reaching 
them  through  systemic  channels.  The  author  is  of  the  opinion 
that  the  anemia  and  morbid  exaltation  of  the  sensory  nerves 
so  frequently  seen  in  subjects  of  chronic  constipation  are 
largely  due  to  fecal  toxemia. 

Deformity  or  displacement  of  the  coccyx  is  a  common 
cause  of  this  condition.  When  the  bone  points  anteriorly,  the 
nerves  in  the  rectum  are  caught  between  it  and  the  fecal  mass 
during  defecation ;  when  it  is  directed  backward,  nerves  inter- 
vening between  it  and  the  surface  are  constantly  irritated  by 
walking,  riding,  sitting  on  hard  seats,  and  sometimes  when 
lying  down.  Tumors  occurring  in  the  rectum,  the  sacro-coc- 
cygeal  region,  and  neighboring  organs  may  induce  neuralgic 
pains.  Again,  rectal  neuralgia  may  be  produced  by  exposure 
to  cold,  sitting  on  cold,  damp  steps,  and  by  operations  which 
are  followed  by  extensive  adhesions  and  cicatrization ;  malaria, 
gout,  rheumatism,  lead  poisoning,  diabetes,  and  Bright's  dis- 
ease have  been  known  to  induce  or  aggravate  this  condition. 

SYMPTOMS 

Patients  suffering  from  rectal  neuralgia  are  usually  anemic, 
extremely  nervous,  and  complain  of  a  tingling  sensation  in  the 
rectum  just  prior  to  the  onset  of  the  pain.  The  pain  is  agoniz- 
ing, and  may  last  for  only  a  few  moments  or  throughout  the 
entire  day,  and  is  so  severe  that  sleep  is  out  of  the  question. 
Ordinarily  it  is  paroxysmal,  located  in  the  lower  third  of  the 
rectum,  and  described  as  being  of  lancinating,  throbbing,  ach- 
ing, burning,  or  stabbing  type.  The  skin  and  mucous  mem- 
brane of  the  lower  rectum  and  anus,  especially  over  the  course 
of  the  nerves,  are  very  tender  during  and  occasionally  for  a 
considerable  time  after  the  attacks.  The  author  has  frequently 
noticed  both  a  tzvitching  of  tJie  sphincters  and  a  quivering  of  the 
buttocks  while  the  pain  was  most  intense  :  he  knows  of  no  other 
disease,  except  fissure,  encountered  in  the  ano-rectal  region  in 
which  the  pain  is  as  severe  and  causes  so  much  prostration. 
Owing  to  the  irritable  state  of  the  pelvic  outlet,  the  sphincters 
in  some  cases   remain   almost   rigid,   and   sometimes  become 


NEURALGIA  AND  HYPERESTHESIA  627 

hypertrophied,  adding  to  the  discomfort  of  the  sufferer  by  de- 
laying or  preventing  defecation.  Now  and  then  patients 
afiflicted  with  rectal  neuralgia  complain  of  tenesmus  and  sensa- 
tions of  heat  and  fullness.  Defecation  rarely,  if  ever,  brings  on 
an- attack  of  neuralgia;  on  the  contrary,  it  sometimes  diminishes 
the  pain  by  removing  the  pressure  of  the  fecal  mass  from  the 
nerves. 

DIAGNOSIS 

The  diagnosis  of  proctalgia  or  sphincteralgia  is  not  difficult 
to  the  expert  in  proctology  who  is  cautious  in  making  his  ex- 
aminations. 

Symptoms  simulating  those  of  neuralgia  are  frequently  in- 
duced by  fissures,  ulceration,  hemorrhoids,  and  foreign  bodies 
in  the  rectum  and  by  certain  affections  of  the  bladder,  urethra, 
prostate,  seminal  vesicles,  ovaries.  Fallopian  tubes,  vagina,  coc- 
cyx, and  sacrum  in  which  the  pain  is  reflected  to  the  rectum. 
In  such  cases  a  correct  diagnosis  can  be  made  only  by  exclusion, 
where  a  most  thorough  and  painstaking  local  and  general  ex- 
amination of  the  patient  has  been  made.  Neuralgia  is  more 
frequently  confused  with  coccygodynia  than  any  other  affection 
common  to  this  region.  In  coccygodynia  there  is  always  a  his- 
tory of  direct  injury  to  the  coccyx;  there  is  little  pain  except  when 
walking,  sitting,  bending  over,  lying  down,  or  during  defeca- 
tion, and  when  there  is  activity  of  the  muscles  at  the  pelvic  outlet. 
Again,  in  coccygodynia  the  bone  is  usually  disjointed,  displaced, 
or  fractured,  and  when  seized  between  the  thumb  and  index 
finger  and  moved  in  whatever  direction  the  most  excruciating 
pain  is  produced  which  subsides  immediately  the  coccyx  is  re- 
leased. In  neuralgia  the  patient  has  great  difficulty  in  locating 
the  exact  point  where  pain  is  felt ;  in  coccygodynia,  on  the  other 
hand,  there  is  little  difficulty  in  this  respect.  The  latter  usually 
occurs  in  robust  persons,  and  the  former  most  frequently  in 
those  who  are  anemic  or  in  a  general  run-down  condition; 
finally,  neuralgic  subjects  are  always  extremely  nervous,  and 
are  relieved  by  defecation,  while  persons  suffering  from  coccy- 
godynia are  rarely  so. 

PROGNOSIS 

The  prognosis  should  be  guarded  in  rectal  neuralgia  be- 
cause in  some  cases  the  pains  will  return  again  and  again  in 
spite  of  the  best  treatment,  until  finally  the  patient  becomes 


628  DISEASES  OF  THE  RECTUM  AND  ANUS 

completely  exhausted.  Sometimes  the  disease  seems  to  run 
its  course  and  disappears  spontaneously.  As  a  rule,  however, 
heroic  treatment  is  required;  but  when  judiciously  carried  out 
a  cure  will  be  effected. 

TREATMENT 

Because  of  the  varied  sources  of  irritation  which  produce 
rectal  neuralgia  no  fixed  rules  can  be  laid  down  to  guide  us  in  the 
treatment  of  all  cases.  Each  patient  requires  a  thorough  exam- 
ination and  individual  treatment.  The  physician  who  ignores 
this  fact  and  follows  routine  methods  will  as  certainly  fail  in  his 
efforts  as  do  those  who  treat  all  piles  in  the  same  manner  irre- 
spective of  their  location,  variety,  or  condition.  The  cause  of 
the  disturbance  must  be  sought  for  in  the  rectum,  neighboring 
organs,  and  distant  parts  until  it  is  found  and  removed. 

Loomis,  of  New  York,  once  said  that  neuralgia  was  sim- 
ply "a  cry  of  the  nerves  for  better  blood."  In  many  instances  this 
is  true,  and  it  is  essential  to  improve  the  quality  as  well  as  the 
quantity  of  blood  in  cases  brought  about  or  aggravated  by 
anemia.  This  can  be  accomplished  by  giving  plenty  of  nour- 
ishing food,  and  removing  the  patient  from  damp  and  dingy 
apartments  to  some  hospital  or  sanatorium  where  the  benefit 
of  the  sun  and  cheerful  surroundings  can  be  had.  In  addition, 
something  to  stimulate  the  appetite  and  build  iip  the  system  in 
general  should  be  given ;  to  this  end  there  is  nothing  better  than 
the  time-tried  remedies :  Russell's  Emulsion,  arsenic,  iron, 
strychnine,  phosphorus,  and  quinine.  The  latter  renders  valuable 
assistance  in  the  treatment  of  those  cases  complicated  by  ma- 
laria. When  syphilis  is  the  cause,  either  in  the  form  of  gum- 
mata  or  ulceration,  antisyphilitic  remedies,  especially  the  potas- 
sium iodide,  are  indicated. 

Many  times  the  pain  becomes  unbearable,  and  something 
must  be  administered  for  temporary  relief ;  for  this  purpose 
morphine,  given  hypodermically,  either  directly  into  the  vicin- 
ity of  pain  or  in  the  arm  or  thigh,  will  prove  most  satisfactory 
to  both  physician  and  patient ;  but  it  should  be  used  with  cau- 
tion. The  bromides  and  chloral  act  well  in  some  cases,  while 
in  a  few  relief  can  be  obtained  only  by  the  use  of  ointments, 
rectal  injections,  or  suppositories  containing  opium  and  bella- 
donna, eucaine,  or  cocaine.  Phenacetin,  acetanilid,  in  from  10- 
to  15-grain   (O.GG  to  1  gram)    doses,  relieve  pain  where  other 


NEURALGIA  AND  HYPERESTHESIA  629 

remedies  fail.  The  good  effect  of  either  of  these  agents  can 
be  enhanced  by  the  addition  of  3  grains  (0.18  gram)  of  caffeine. 
Remedies  for  the  rehef  of  pain  should  be  given  with  caution,  for 
many  of  these  cases  are  persistent,  and  the  sufferer  easily  be- 
comes addicted  to  the  use  of  drugs.  Davis  reports  the  cure  of 
two  typic  cases  of  rectal  neuralgia.  The  first  patient  was  re- 
lieved in  two  days  by  the  following  remedies : — 

IJ  Nitrous  ether    §ij         60 

Tincture  of  belladonna 3ij  8 

M.    Sig. :    Teaspoonful  (4.0  grams)  in  sweetened  water  every  four  hours. 

Also  an  enema  containing  20  drops  (1.3  grams)  of  tincture 
of  belladonna  in  half  a  teacupful  (90  grams)  of  warm  water 
every  three  hours.  In  his  second  case  the  treatment  differed 
slightly,  as  will  be  noticed  by  the  following  prescription : — 

IJ  Chloroform, 

Tincture  of  belladonna aa  3iij        121 

Syrup  of  orange-peel ^iij      100 

M.  Sig.:  Teaspoonful  (4.0  grams)  every  two  hours  until  pupil  dilated; 
then  every  four  hours. 

In  addition  to  this,  he  gave  belladonna  per  rectum,  as  in 
the  previous  case.  After  all  pain  had  subsided  8  drops  (0.3 
gram)  of  hydrochloric  acid  in  sweetened  water  was  given  four 
times  daily  to  restore  the  appetite.  The  enemata  were  con- 
tinued as  a  precautionary  measure  for  some  time  after  pain  had 
stopped.  In  the  treatment  of  this  affection  it  is  necessary  to 
keep  the  bowel  open  with  some  mild  purgative,  and  to  have  the 
patient  rest  quietly  in  bed  as  much  as  possible. 

Heat  properly  applied  lessens  pain  in  most  cases.  It  may 
be  used  in  the  form  of  a  poultice,  hot-water  bag,  or  hot-air 
apparatus  placed  over  the  sacrum  and  ano-gluteal  region ; 
again,  the  rectum  may  be  injected  with  oils  as  hot  as  can  be 
borne  or  irrigated  at  short  intervals  or  continuously  with  water 
or  hot  medicated  solutions.  In  exceptional  instances  heat  ag- 
gravates the  neuralgia;  in  such  cases  the  ice-bag  or  coil,  and 
cold  irrigations  or  freezing  the  painful  spot  with  liquid  air  or 
ether-spray,  renders  these  patients  more  comfortable.  Counter- 
irritants  are  of  value  in  the  treatment  of  neuralgia ;  but  it 
is  frequently  necessary  to  try  one  after  another  until  one  is 
found  which  gives  relief.  The  author  has  found  the  Paquelin 
cautery  the  most  reliable,  although  chloroform,  aconite,  cap- 


630  DISEASES  OF  THE  RECTUM  AND  ANUS 

sicum,  camphor,  turpentine,  conium,  iodine,  the  oil  of  mustard, 
and  sinapisms  of  various  kinds  have  at  times  accompHshed  the 
desired  results.  They  should  be  applied  over  the  sacro-coc- 
cygeal  region.  Electricity  is  not  to  be  relied  upon,  though  it 
occasionally  does  some  good;  it  may  be  used  upon  the  surface 
or  inside  the  rectum,  and  the  continuous  current  appears  to 
give  the  best  results.  Einhorn  obtained  beneficial  effects  from 
the  galvanic  current  by  introducing  the  negative  pole  into  the 
rectum  and  so  arranging  it  that  fluid  could  run  into  the  bowel 
at  the  same  time  the  current  was  passing.  When  intelligently 
practiced  gentle  massage,  either  within  the  rectum  or  over  the 
sacro-coccygeal  region,  is  a  valuable  adjunct  to  the  treatment. 

When  neuralgia  is  secondary  to  extensive  scars  resulting 
from  an  operation  about  the  rectum,  much  benefit  is  derived 
by  removing  as  much  as  possible  of  the  cicatricial  tissue.  The 
writer  cured  a  most  obstinate  case  of  rectal  neuralgia  in  this 
way.  When  the  contractions  caused  by  a  scar  are  located 
within  the  bowel,  the  constricting  area  should  be  thoroughly 
divulsed  as  often  as  is  necessary.  In  not  a  few  cases  of  neu- 
ralgia accompanied  by  hypertrophy  of  the  sphincter-muscle 
the  writer  has  effected  a  cure  simply  by  divulsing  the  muscle 
thoroughly  in  every  direction.  He  has  also  known  good  results 
to  follow  this  operation  in  cases  in  which  there  was  neither  con- 
striction of  the  rectum  nor  apparent  hypertrophy  of  the  sphinc- 
ter ;  the  good  results  obtained  were  ascribed  to  nerve-stretch- 
ing in  some  cases  and  in  others  to  the  psychological  effect  of 
the  operation.  Where  divulsion  does  not  afford  relief  in  this 
class  of  cases,  the  muscle  should  be  completely  divided  with  a 
sharp  bistoury  under  local  anesthesia. 

In  those  instances  in  which  the  coccyx  is  displaced  ante- 
riorly against  the  rectum  or  posteriorly  against  the  skin,  pro- 
ducing neuralgic  pains,  coccygodectomy  is  indicated.  The 
bone  can  be  quickly  excised  by  the  plan  suggested  elsewhere 
for  its  removal  in  cases  of  coccygodynia. 

In  conclusion,  the  importance  of  removing  hemorrhoids 
and  polyps,  and  of  curing  fissures,  ulcers,  or  prolapse  when 
present  before  any  attempt  is  made  to  alleviate  the  neuralgia 
cannot  be  too  strongly  emphasized.  Only  too  frequently  the 
pains  induced  by  these  afTections  simulate  and  are  mistaken 
for  those  of  rectal  neuralgia. 


NEURALGIA  AND  HYPERESTHESIA  631 

HYPERESTHESIA  (HYSTERICAL  RECTUM) 

Hyperesthesia  of  the  rectum  is  an  affection  involving  the 
terminal  nerve-filaments  and  rendering  the  mucosa  hypersen- 
sitive in  spots.  The  hyperesthetic  areas  may  be  single  or  mul- 
tiple and  vary  in  extent  from  one-half  to  one  inch  (1.27  to 
2.54  centimeters)  in  breadth.  They  may  be  situated  in  any  part 
of  the  rectum,  but  usually  occur  within  the  anal  canal.  The 
mucous  membrane  of  these  areas  is  not  swollen,  is  unbroken 
and  smooth;  it  is,  however,  somewhat  more  highly  colored  than 
normal. 

Rectal  hyperesthesia  occurs  in  both  sexes.  It  is  more 
common  in  women  than  in  men,  and  exceedingly  rare  in  chil- 
dren. It  is  met  with  most  frequently  in  persons  of  high  intelli- 
gence, sedentary  habits,  or  neurotic  tendency  and  in  those 
suffering  from  chronic  constipation. 

Constipation  seems  to  be  the  most  common  cause  of  hy- 
peresthesia of  the  rectum,  and  it  is  quite  probable  that  the  con- 
gestion of  the  affected  areas  and  the  irritability  of  the  nerves 
is  due  to  pressure  exerted  upon  them  by  retained  and  hardened 
feces. 

SYMPTOMS 

The  principal  symptoms  of  this  affection  are  pain,  tenes- 
mus; and  a  sensation  which  appears  at  inopportune  times  and 
produces  a  desire  to  defecate,  although  the  bowels  may  have 
been  evacuated  immediately  before.  The  pain  is  most  severe 
just  before  stool  and  when  the  feces  have  been  allowed  to  ac- 
cumulate, and  is  greatly  relieved  by  defecation.  The  tenesmus 
and  desire  for  stool  may  be  brought  on  at  any  time  by  excite- 
ment or  anxiety. 

DIAGNOSIS 

Hyperesthesia  may  be  confused  with  neuralgia.  In  hyper- 
esthesia the  pain  is  more  constant,  sharp  and  smarting,  or  burn- 
ing in  character ;  in  neuralgia  it  is  paroxysmal  and  agonizing. 
Again,  the  pain  in  hyperesthesia  is  principally  confined  to  the 
affected  areas,  while  in  neuralgia  it  is  more  general,  and  may 
be  reflected  to  the  coccyx.  Moreover,  in  hyperesthesia  the 
most  intense  suffering  is  produced  when  the  oversensitive  spots 
are  touched;  in  neuralgia,  pressure  produces  only  a  sensation 
of  soreness. 

This    condition    has    been    frequently    diagnosticated    as 


633  DISEASES  OF  THE  RECTUM  AND  ANUS 

"hysterical  rectum,"  because  of  the  pecuHar  character  of  the 
suffering,  and  the  fact  that  the  examiner,  in  searching  for  a 
more  extensive  lesion,  has  overlooked  the  slightly  congested, 
hypersensitive  spots.  Hyperesthesia  of  the  rectum  may  be  mis- 
taken for  painful  ulcer,  but  a  careful  examination  will  reveal  the 
true  condition. 

TREATMENT 

The  treatment  of  hyperesthesia  of  the  rectum  must  be 
adapted  to  the  case.  The  first  and  most  important  step  is  to 
relieve  constipation  and  secure  a  daily  soft  stool.  This  can  be 
accomplished  by  regulating  the  diet  and  establishing  a  regular 
time  for  defecation ;  if  necessary,  some  effective  laxative  min- 
eral water,  such  as  Carabafia,  should  be  prescribed.  Thorough 
divulsion  of  the  anal  canal  sometimes  proves  effective  m  these 
cases ;  the  good  effects  following  this  operation  may  be  due  to 
stretching  the  nerves,  but  is  more  likely  attributable  to  the 
relief  of  constipation.  Prolonged  irrigation  of  the  rectum  with 
either  cold  or  hot  water  relieves  the  suffering  in  some  cases ; 
in  others  no  benefit  is  derived  from  it.  Soothing  suppositories, 
ointments,  or  enemata  will  be  found  useful,  but  opiates  should 
be  prescribed  cautiously,  since  this  condition  tends  to  chronicity 
and  there  is  danger  of  forming  the  drug  habit.  In  obstinate 
cases  the  application  of  stimulating  or  caustic  remedies  will 
prove  effective,  and,  when  these  fail,  all  hyperesthetic  spots 
should  be  cauterised  with  the  Paquelin  cautery-point  and  after- 
ward treated  as  simple  ulcerations  from  other  causes. 

ILLUSTRATIVE  CASES 
Case  XXXIZ.  Neuralgia  of  the  Rectum. — In  December,  1892,  I  was 
called  to  see  Mrs.  B.,  aged  31  years,  who,  judging  from  external  appearances, 
was  in  excellent  health.  On  inquiry  it  was  learaed  that  off  and  on  for  the 
past  six  months  she  had  suffered  from  severe  spasmodic  pains  in  the  back. 
The  pains  were  often  so  severe  as  to  prevent  sleep  at  night.  When  aslced  to 
locate  the  pain,  she  placed  her  finger  over  the  upper  portion  of  the  coccyx, 
stating  that  it  sometimes  went  a  little  higher.  Her  bowels  were  regular;  she 
had  never  suffered  from  piles  or  had  any  discharge  from  the  rectum.  Pain 
was  the  only  disturbance  complained  of.  To  relieve  this  she  used  suppositories 
composed  of  morphine  and  belladonna,  which  afforded  only  temporary  relief. 
She  desired  to  know  if  an  operation  were  indicated.  On  examination  ttie  coc- 
cyx, anus,  and  rectum  proved  to  be  perfectly  sound;  no  fissure,  ulceration,  or 
inflammation  of  the  mucous  membrane  or  adjoining  skin  could  be  located, 
although  the  examination  was  most  thorough.  A  medium-sized  rectal  bougie 
passed  up  the  bowel  for  ten  inches   (2.5  decimeters)   failed  to  cause  any  un- 


NEURALGIA  AND  HYPERESTHESIA  633 

usual  pain  or  to  reveal  any  obstruction.  It  must  be  confessed  that  no  little 
embarrassment  as  to  the  cause  of  the  pain  was  experienced.  After  due  con- 
sideration it  was  decided  to  be  neuralgic  in  nature  and  needed  only  some  trivial 
operation  to  effect  a  cure.  Divulsion  of  the  sphincter-muscles  was  advised  and 
readily  consented  to.  On  the  following  morning,  under  chloroform,  the  mus- 
cles were  thoroughly  divulsed  in  every  direction,  the  rectum  irrigated,  and  the 
patient  then  placed  in  bed.  On  the  evening  of  the  third  day  the  administration 
of  a  Seidlitz  powder  secured  a  copious  movement,  after  which  the  rectum  was 
irrigated  again.  From  this  time  onward  the  patient  was  allowed  to  walk 
about  the  room.  She  did  not  complain  of  pain  once  after  the  operation,  and 
when  discharged  after  one  week's  treatment  she  said  she  had  never  felt  better. 
Opportunity  was  afforded  to  watch  this  patient  for  a  year  or  more,  and  it  was 
ascertained  that  the  pain  never  recurred. 

Just  why  stretching  of  the  sphincters  cured  this  patient  could  not  be  fully 
explained.  Possibly  her  sufferings  may  have  been  imaginary.  This,  however, 
is  extremely  doubtful,  for  she  seemed  to  be  a  sensible  woman.  On  the  other 
hand,  there  may  have  been  some  irritation  of  the  terminal  nerve-filaments 
from  which  the  pain  was  reflected  to  the  coccyx,  and  the  source  of  the  irri- 
tation was  destroyed  by  the  divulsion. 

Case  XL.  Neuralgia  Due  to  Scar-tissue. — Mr.  J.  M.,  aged  40,  complained 
of  very  severe,  almost  constant,  aching  pains  in  the  neighborhood  of  the 
coccyx.  He  had  been  operated  on  for  internal  piles  one  year  previous,  and 
five  tumors  had  been  removed  by  the  ligature.  The  pains  in  the  region  of  the 
coccyx  commenced  six  months  after  the  operation.  A  thorough  examination 
was  made,  but  no  local  pathologic  condition  was  found  other  than  a  consid- 
erable amount  of  cicatricial  tissue  resulting  from  the  operation.  Having  pre- 
viously tried  divulsion  with  success,  I  determined  to  try  it  in  this  case.  Chloro- 
form was  promptly  administered  and  the  muscles  thoroughly  divulsed  in  every 
direction.  This  not  proving  entirely  satisfactory,  the  scar-tissue  was  freely 
incised  with  a  blunt-pointed  bistoury  until  no  contraction  remained.  The 
after-treatment  was  the  same  as  in  the  previous  case,  except  that  a  full-sized 
bougie  was  passed  daily  to  prevent  too  much  contraction.  This  patient  made 
an  uninterrupted  recovery  and  is  perfectly  well  to-day.  Close  study  of  this 
case  led  to  the  conclusion  that  the  pains  were  caused  by  the  nerve-filaments 
being  encroached  upon  by  the  scar-tissue,  and  that  they  were  permanently  dis- 
sipated either  by  the  dilatation  or  by  the  incisions.  And  why  should  not  this 
be?  It  is  a  well-known  fact  that  similar  pains  are  produced  in  an  amputa- 
tion stump  left  after  removal  of  a  limb  and  in  w^ich  the  nerve  has  become 
engaged  in  the  scar;  and  it  is  equally  well  known  that  the  pain  ceases  imme- 
diately the  nerve  is  liberated. 

Case  XLI.  Neuralgia  Due  to  a  Dislocated  Coccyx. — A  lady,  aged  30,  of 
good  general  health,  came  to  me  suffering  from  neuralgic  pains  about  the 
rectum.  She  was  very  nervous,  complained  of  great  pain  when  sitting  on  a 
hard  seat,  and  believed  that  her  trouble  was  due  to  a  fall  received  some  months 
previously.  Examination  revealed  a  normal  rectum.  The  coccyx,  however, 
was  very  prominent,  and  the  lower  two  segments  were  dislocated  backward, 
bulging  the  skin  outward. 

Treatment. — The  sphincters  were  divulsed,  the  displaced  segments  of  bone 
removed,  the  wound  closed,  iodoform-gauze  dressing  applied,  and  the  patient 


034  DISEASES  OF  THE  RECTUM  AND  ANUS 

put  to  bed.     In  ten  days  she  was  well.     Six  months  later  the  pains  had  not 
returned. 

Case  XLII.  Hyperesthesia  of  the  Rectum. — A  minister,  38  years  old, 
came  to  me  for  relief  from  rectal  trouble.  He  had  a  free  action  from  the  bowels 
every  morning,  and  never  passed  any  blood,  mucus,  or  pus.  He  complained 
of  severe  pains  in  the  rectum  and  neighborhood  of  the  coccyx  for  a  considerable 
time  before  and  after  each  stool.  Being  a  public  speaker,  he  did  not  mind  the 
pain  so  much  as  the  urgent  desire  to  go  to  stool  at  the  most  inopportune 
times.  On  several  occasions  at  the  beginning  of  his  sermon  he  had  been  seized 
with  this  irresistible  impulse  immediately  to  empty  the  bowel,  and  he  had 
excused  himself  on  the  grounds  of  illness.  Since  any  unusual  excitement 
brought  about  this  desire,  he  would  be  obliged  to  give  up  his  profession  in 
consequence  if  he  could  not  obtain  relief.  Examination  revealed  two  bright- 
red  hypersensitive  spots,  each  about  an  inch  (2.54  centimeters)  in  diameter, 
located  upon  the  posterior  rectal  wall.  During  the  next  two  months  topic 
applications  of  various  kinds  were  made  without  effect.  Finally,  in  despera- 
tion, the  Paquelin  cautery  was  resorted  to.  The  entire  surface  of  both  spots 
was  thoroughly  cauterized,  and  treated  afterward  as  ulcers.  They  healed 
nicely,  and,  from  the  time  the  cicatrix  became  firm,  the  pain  and  desire  to  go 
to  stool  at  unnatural  times  ceased. 


IITERATTIRE  ON  NEURALGIA  OF  THE  RECTUM 


Allingham:  "Rectal  Neuralgia,"  "Diseases  of  the  Rectum  and  Anus,"  p.  280, 
1896. 

J3ondurant:  "Neuralgia,"  "Sajous's  Analytical  Cyclopedia  of  Practical  Medi- 
cine," vol.  V,  p.  178,  1899. 

Bruce:    "Treatment  of  Neuralgia,"  "Practical  Medicine,"  p.  578,  1900. 

Dardel:  "Deux  faits  de  Nevrose  Ano-vesicale,"  etc.,  Mem.  Soc.  des  Sci.  Med. 
de  Lyon,  vii,  p.  200. 

Davis:    Cliicago  Medical  Examiner,  ix,  No.  3,  1868. 

Einhorn:    "Hypogastric  Neuralgia,"  "Diseases  of  the  Intestines,"  p.  333,  1900. 

Eitner:    "Proktalgia  Nervosa,"  Med.  Zeit.,  xi,  p.  202.     Berlin,  1842. 

Goodsall:  "The  Hysterical  Rectum,"  read  at  the  American  Medical  Associa- 
tion, May,  1888. 

Hird:    "Painful  Neuralgia  of  the  Rectum,"  Lancet  (London),  ii,  p.  380,  1840-41. 

Mitchell:    "Anal  and  Perineal  Neuralgia,"  Phila.  Med.  Times,  iii,  pp.  65-67,  1873. 

Osier:    "Visceral  Neuralgia,"  "Practice  of  Medicine,"  p.  1106,  1898. 

Shoemaker:    Brit.  Med.  Jour.,  vol.  ii,  p.  712,  1887. 

Simon:  "De  la  Nevralgia  de  la  partie  inferieure  du  rectum,"  etc..  Bull.  G^n. 
de  Therap.,  etc.,  xxiv,  p.  88.    Paris,  1843. 

Thompson:    "Neuralgia  of  the  Rectum,"  "Practice  of  Medicine,"  p.  424,  1900. 

Tyson:    "Neuralgia  of  the  Rectum,"  "Practice  of  Medicine,"  p.  421,  1900. 


CHAPTER  XXXVII 

ENTEROLITHS  AND  CONCRETIONS 

Intestinal  Calculi  have  been  found  in  every  portion  of 
the  intestine.  Writers  generally  agree  that  they  are  met  with 
more  frequently  in  the  colon  and  small  intestine  than  in  the 
lower  bowel.  The  54  cases  collected  by  the  author  show  the 
contrary,  for  out  of  this  number  34  were  located  in  the  rectum. 
They  are  found  more  frequently  in  women  than  men  and  in 
persons  past  40,  only  1  case  (except  those  included  in  the  au- 
thor's table  of  cases),  that  of  Peacock's,  having  been  reported 
where  the  patient's  age  was  under  30.  Brinton  maintains  that 
the  average  age  is  53  ^/^  years.  There  are  many  varieties  of 
intestinal  calculi  and  concretions,  and  the  author  has  been  ac- 
customed to  group  them  as  follows : — 


1. 

Gall-stones    (biliary    cal- 

5. 

Pancreatic  calculi. 

culi). 

6. 

Urinary  calculi. 

2. 

Hairy    concretions    (be- 

7. 

Coproliths. 

zoars). 

8. 

Prostatic  calculi. 

3. 

Avenoliths    (oat-stones). 

9. 

Miscellaneous    concre- 

4. 

Enteroliths    (intestinal 
calculi). 

tions. 

Gall-stones  (biliary  calculi)  are  met  with  more  frequently 
than  are  all  other  forms  of  intestinal  concretions.  They  enter 
the  intestine  through  the  duct  when  small,  and  by  ulceration 
and  anastomosis  when  large  and  irregular.  In  Dennis's  eighty- 
three  cases  of  gall-stone  obstruction,  operation  and  autopsy 
demonstrated  the  fact  that  these  stones  are  not  partial  to  any 
particular  region  of  the  intestine. 

The  author  has  on  several  occasions  found  gall-stones  in 
the  feces,  and  has  twice  removed  them  from  the  rectum,  where 
they  had  become  firmly  encysted;  in  each  case  they  caused  a 
great  deal  of  pain,  irritation,  and  sphincterismus.  They  were 
composed  largely  of  bile-pigment,  lime,  and  cholesterin.  They 
may  be  single  or  multiple ;  occasionally  they  are  found  in  a 
mass,  invested  in  a  coating  of  fecal  matter  and  salts,  forming 
a  concretion  of  sufficient  size  to  fill  the  rectum,  producing  com- 
plete obstruction.    (See  section  on  examination  of  feces.) 

(635) 


636  DISEASES  OF  THE  RECTUM  AND  ANUS 

Hairy  Concretions  (Bezoars).i — Balls  of  hair  (Fig.  208)  are 
frequently. found  in  the  stomach  and  intestines  of  inferior  ani- 
mals who  hck  themselves.  Similar  concretions  have  been  found 
in  the  human  subject,  Ritchie's  case  being  the  most  celebrated 
of  this  class.  He  treated  a  girl  for  ileus  and  intestinal  rupture, 
but  autopsy  proved  that  her  suffering  was  caused  by  a  mass 
of  hair  completely  filling  and  making  a  perfect  mold  of  the 
stomach,  and  two  smaller  masses  were  found  in  the  intestines. 


Fig.  208. — Hair  Ball  (Bezoar)  from  the  Intestine  of  a  Horse. 

Cases  have  been  recorded  where  hair  balls  have  found  their 
way  into  the  rectum,  caused  by  the  disintegration  of  dermoid 
cysts  of  the  ovaries.  The  author  knows  of  a  case  where  a  tumor, 
the  size  of  an  orange,  composed  of  finely  masticated  wood- 
fiber,  was  successfully  removed  from  the  intestine  of  a  woman. 
It  was  caused  by  the  chewing  and  swallowing  of  toothpicks :  a 
not  uncommon  habit  in  certain  parts  of  the  West. 

1  Jacobson  (Trans.  Med.  Soc.  State  V.  Y.,  page  386,  1901)  reports  the  successful 
removal  by  laparotomy  of  a  mass  of  hair  which  completely  filled  the  stomach  of  a 
young  girl. 


ENTEROLITHS  AND  CONCRETIOlS,  S 


637 


Avenoliths  (Oat-stones).  —  Concretions  of  this  variety  are 
rarely  seen  in  this  country,  but  are  not  infrequently  met  with  in 
Scotland.  They  are  found  principally  in  persons  who  consume 
large  quantities  of  oatmeal ;  they  occur  less  frequently  at  the 
present  time  than  formerly,  because  the  Scotch  are  now  eating 
more  meat  and  less  meal.  Avenoliths  vary  from  cherry  to 
orange  size,  and  are  of  firm  consistence.  They  are  oval  or  flat 
in  shape,  dependent  upon  location  and  pressure,  and  yellow 
in  color  unless  mixed  with  salts,  when  they  have  a  whitish  ap- 
pearance.    "They  are  formed  of  concentric  rings  of  vegetable 


Fig.  209.— Enterolith  from  the  Rectum. 


fiber,  intermingled  with  lime,  water,  feces,  and  silica  from  the 
oat"  (Maclagan).  During  the  Irish  famine  of  1846  many  con- 
cretions of  a  similar  nature  were  encountered,  caused  by  eating 
the  skins  of  potatoes.  In  some  cases  it  was  found  that  a 
cherry-stone  or  plum-stone  acted  as  a  nucleus  for  their  for- 
mation. Any  vegetable  food  having  long  and  coarse  fibers,  if 
eaten  in  large  quantities,  may  result  in  the  formation  of  an 
intestinal  concretion  of  this  type. 

Enteroliths  (Intestinal  Calculi).  —  Stony  concretions  other 
than  gall-stones  have  been  encountered  in  all  parts  of  the  in- 
testine, but  less  frequently  (see  Dr.  Fuller's  case.  Fig.  209). 


638  DISEASES  OF  THE  RECTUM  AND  ANUS 

Enteroliths  are  rarely  met  with  under  forty,  and  occur  more 
frequently  in  women  than  men.  They  may  be  small  and  ir- 
regular in  shape  or  large  and  oval,  and  vary  in  weight  from  a 
few  grains  to  15  ounces  (456  grams).  When  multiple  they  oc- 
casionally weigh  even  more.  Niemeyer  has  recorded  a  case 
where  32  stones  were  evacuated,  weighing,  in  all,  2  Y2  pounds 
(1300  grams).  Enteroliths  are  located  in  the  colon  and  rectum 
more  frequently  than  in  the  small  intestine. 

Composition.  —  The  make-up  of  intestinal  calculi  differs 
slightly.  Most  of  them,  however,  are  composed  principally  of 
the    phosphates    of    lime,    magnesia,    ammonia,    and    organic 


Fig.  210. — Urinary  Calculus,  Weighing  more  than  Four  Ounces,  which  Pro- 
jected into  the  Rectum,  Causing  Stricture  and  Recto-vesical  Fistula. 
(Author's  Case.) 


matter.  They  are  not  uncommon  in  persons  who  have  taken 
for  a  considerable  time  large  doses  of  mineral  remedies,  such 
as  bismuth,  chalk,  benzoin,  and  lime.  The  author  has  on  three 
occasions  removed  through  a  colostomy  opening  enormous, 
black,  putty-like  masses,  composed  of  bismuth ;  in  each  case 
large  doses  of  this  drug  had  been  given  daily  for  the  relief  of  a 
colitis  and  frequent  stools,  where  the  irritation  causing  the 
watery  evacuations  was  induced  by  a  mechanic  obstruction  of 
the  rectum  due  to  carcinoma. 

Pancreatic  Calculi. — These  concretions  are  rarely  found  in 
the  intestine,  and  when  present  are  so  small  that  they  do  not 


ENTEROLITHS  AND  CONCRETIONS  639 

produce  any  disturbance  beyond  a  slight  irritation.  They  may 
be  single  or  multiple,  smooth  and  round,  or  faceted  and  ir- 
regular in  shape,  are  very  brittle,  and  find  their  way  into  the 
intestine  by  ulceration  or  through  the  duct. 

Urinary  Calculi  occasionally  find  an  exit  through  the  rec- 
tum, the  result  of  pressure-ulceration  from  a  stone  in  the 
bladder.  The  author  once  treated  a  gentleman  for  rectal  strict- 
ure caused  by  a  large  urinary  calculus  weighing  more  than  4 
ounces  (124  grams)  (Fig.  210).  In  this  case  the  end  of  the 
stone  projected  into  the  bowel.  It  was  removed  by  perineal 
section,  because  its  attachment  to  the  bladder  prevented  its 
delivery  through  the  anus.^  It  is  only  in  exceptional  cases  that 
these  stones  are  of  sufficient  size  to  cause  intestinal  obstruction. 

Coproliths  (Fecoliths,  or  Fecal  Calculi)  are  distinguished  from 
fecal  tumors,  known  as  impacted  feces,  by  their  smaller  size 
and  stony  hardness.  Usually  they  are  ovoid  in  shape  when 
single,  or  faceted  and  fit  perfectly  the  one  with  the  other  when 
multiple.  On  two  occasions  the  author  has  removed  them  in 
the  form  of  scales;  they  were  slightly  soluble  in  water,  pro- 
duced a  stony  sound  when  dropped  on  a  hard  floor,  and  were 
composed  of  the  residue  of  food,  combined  with  earthy  or 
chalky  matter. 

Prostatic  Calculi,  according  to  some  writers,  are  said  to 
occasionally  find  their  way  into  the  lower  bowel  through  an 
ulcerative  process.  It  is  questionable  if  this  really  occurs. 
Even  if  they  should  enter  the  bowel,  no  serious  annoyance 
would  follow,  because  of  their  diminutive  size. 

Miscellaneous  Concretions.  —  Concretions,  of  variable  size 
and  shape,  composed  of  fruit-stones  and  berry-seeds  incased 
in  a  coating  of  fecal  matter,  are  of  common  occurrence,  espe- 
cially during  the  summer  months,  when  fruit  is  plentiful.  Such 
accumulations  occur  more  frequently  in  children  than  in  adults, 
and  boys  are  the  ones  who  suffer  most.  The  author  has  several 
times  removed  from  the  rectum  and  sigmoid  enormous  quan- 
tities of  blackberry-seeds;  persimmon-,  cherry-,  and  plum- 
stones,  which  caused  partial  or  complete  obstruction.  Some- 
times pins,  fish-bones,  coins,  or  other  foreign  bodies  which 
have  been  swallowed  find  their  way  into  the  intestine  and  act 
as  a  nucleus  around  which  large  fecal  tumors  form. 

1  The  operation  was  performed  by  Dr.  Jabez  N.  Jackson,  of  Kansas  City,  assisted 
by  the  author. 


640  DISEASES  OF  THE  RECTUM  AND  AXUS 

SYMPTOMS 

The  manifestations  produced  by  intestinal  calculi  and 
concretions  vary,  depending  upon  many  things.  The  size, 
number,  and  shape  of  the  offending  bodies  must  be  taken  into 
consideration;  also  the  length  of  time  since  they  made  their 
presence  known,  and,  furthermore,  the  amount  of  occlusion 
produced  by  them. 

When  small  and  single,  and  sometimes  when  multiple  and 
massed  together,  they  are  evacuated  without  pain  or  other 
serious  disturbance.  Enteroliths  having  sharp  and  irregular 
surfaces  are  particularly  apt  to  lodge  at  some  point  in  the  in- 
testine and  cause  occlusion  on  account  of  the  local  irritation, 
resulting  in  inflammation  and  prolonged  contraction  of  the 
muscular  coat.  The  obstruction  is  likely  to  occur  at  a  point 
where  the  bowel  is  narrowed  by  a  stricture,  tumor,  or  adhe- 
sions, and  where  it  is  inflamed  from  any  cause.  "Usually  a 
foreign  body  as  large  as  the  caliber  of  the  small  bowel  will 
safely  pass  through  the  intestine  when  there  is  no  change  in 
the  gut-wall"  (Senn).  It  is  a  well-known  fact,  however,  that 
small  concretions  sometimes  produce  obstruction,  while  at 
other  times  much  larger  bodies  are  evacuated  with  ease. 
Enteroliths  which  become  encysted  or  lodged  in  a  fold  of  the 
bowel  rarely  produce  symptoms  of  acute  obstruction,  but  do 
cause  colicky  pains,  diarrhea,  constipation,  inflammation,  re- 
tention of  gases,  ulceration,  and  occasionally  the  discharges 
of  pus,  blood,  and  mucus.  The  date  of  entrance  of  gall-stones 
into  the  intestine  is  generally  marked  by  a  coincident  hemor- 
rhage. The  symptoms  induced  by  intestinal  calculi  do  not 
differ  widely  from  those  produced  by  occlusion  from  other 
causes,  with  the  possible  exception  that  vomiting  begins  earlier. 
When  enteroliths  cause  complete  occlusion,  sooner  or  late  we 
get  the  following  manifestations  if  the  disease  is  allowed  an 
uninterrupted  course : — 

fa)  Obstipation,  fb)  Violent  abdominal  pains,  (c)  Local 
tenderness,  (d)  Vomiting  of  the  gastric  contents,  bile,  and 
finally  fecal  matter,  (e)  Tympanites,  local  or  general,  (f) 
Pulse  fast  and  thread-like,  fg)  Variable  temperature,  (h) 
Cold  perspiration.  fi)  Facial  expression  of  anguish.  (j) 
Rupture  of  the  intestine,  (k)  Peritonitis.  (1)  Collapse  and 
death. 

When  the  obstruction  is  located  in  the  rectum,  local  pain, 


ENTEROLITHS  AND  CONCRETIONS  641 

hemorrhage,  straining,  and  sensations  of  weight  and  fullness 
in  the  lower  bowel  may  be  added  to  the  symptoms  just  named. 

DIAGNOSIS 

Many  times  it  is  impossible  to  differentiate  between  an 
obstruction  caused  by  an  intestinal  concretion  and  a  similar 
condition  from  some  other  cause.  "In  cases  of  acute  intestinal 
occlusion  in  elderly  persons  zvJiere  there  is  an  absence  of  deilnite 
signs  pointing  to  some  other  ailment,  the  presence  of  an  enterolith 
or  gall-stones  should  be  suspected"  (Dennis).^  In  children  it  is  im- 
portant to  find  out  what  they  have  eaten  in  order  to  determine 
if  a  collection  of  fruit-stones  is  causing  the  trouble.  Occasion- 
ally intestinal  calculi  can  be  located  by  palpating  the  abdomen. 
When  situated  in  the  sigmoid  flexure  or  rectum,  the  diagnosis 
is  made  easy  by  means  of  digital  examination  and  the  aid  of 
the  proctoscope  and  colon-tubes.  In  most  cases,  unfortunately, 
the  exact  location  and  nature  of  the  offending  body  are  not 
known  until  revealed  by  operation  or  autopsy.  A  chemic  and 
microscopic  examination  should  be  made  of  each  concretion 
obtained  by  operation  or  evacuation.  Some  idea  may  then  be 
had  of  the  patient's  liability  to  another  attack,  for,  should  it 
prove  to  be  a  biliary  calculus  and  other  stones  are  left  in  the 
gall-bladder,  a  second  attack  is  likely  to  follow. 

TREATMENT 

The  measures  to  be  instituted  for  the  relief  of  disturbances 
arising  from  enteroliths  and  other  forms  of  intestinal  concre- 
tions require  to  be  changed  from  time  to  time,  depending  not 
only  upon  the  manifestations  present,  but  also  upon  their  loca- 
tion. It  ib  a  fortunate  thing  for  the  patient  when  they  are  lo- 
cated in  the  rectum  or  sigmoid  flexure,  because  when  in  this 
region  it  is,  with  a  good  light,  a  large  proctoscope,  and  the  au- 
thor's rectal  forceps  (Fig.  172),  a  comparatively  easy  matter  to 
see  and  remove  them.  When  situated  in  the  colon  and  small 
intestine,  the  treatment  becomes  more  difficult  and  dangerous. 
Massage  and  mild  salines  are  indicated  to  dislodge  them  when 
the  obstruction  is  incomplete,  but  strong  purgatives  never. 
Sometimes  they  may  be  evacuated  by  means  of  frequent  and 
copious  enemata,  composed  of  water,  oil,  and  glycerin.  When 
there  is  rigidity  of  the  abdominal  muscles,  great  pain  and  spasm 

1  Italics  by  the  author. 


642 


DISEASES  OF  THE  RECTUM  AND  ANUS 


of  the  bowel  musculature,  hot  fomentations  afford  much  relief 
and  produce  relaxation  of  these  parts.  Palliative  measures 
should  be  discarded  when  it  becomes  evident  that  occlusion  is 
complete,  for  under  such  circumstances  nothing  short  of  lapa- 
rotomy, the  opening  of  the  intestine  and  removal  of  the  stone 
will  save  the  patient.  Khalofoff  has  on  two  occasions  success- 
fully removed  enteroliths  by  making  a  colotomy.  Concretions 
sometimes  become  firmly  encysted,  and  extensive  dissections 
and  considerable  time  are  required  to  deliver  them. 

Table  XXV.     Synopsis  of  Fifty-four  Cases  of  Enteroliths  and 
Intestinal  Concretions  Collected  by  the  Author 


1" 

Age 

Sex 

Location 

Comjiosition 

By  whom 
Reported 

1 

1 

25 

Male 

Jejunum 

Desiccated  bile,  feces,  inorganic  salts. 

Konig. 

2 

12 

50 

Female 

Mg  and  pot.  phos|iliate,  fat.  amorphous  material. 

Bieber. 

3 

4 

52 

Ileum 

Inorganic  salts,  hair,  feces,  cotton-fiber. 

Mehrlust. 

4 

2 

67 

** 

Jejunum 

Pot.  sulphate  and  phosphate,  mg.  and  amnion,  phosphate, 
feces. 

EUenbogeu. 

5 

48 

" 

Cecum 

Starch,  fat.  dyalisin,  inorganic  matter,  feces. 

Burns. 

6 

73 

Rectum 

Largely  mineral  phosphates  and  carbonates. 

Holden. 

7 

55 

Male 

'* 

Nucleus  of  plum-stone,  bile-pigment,  cliolesterin. 

Boeder. 

8 

60 

Female 

" 

Not  given. 

Welch. 

9 

70 

Male 

Ileum 

Mineral  phosphates  and  carbonates. 

Van  Buren. 

10 

72 

'• 

Cholesteriu,  bile-pigment,  salts 

Specht. 

11 

68 

" 

Cecum 

Amnion,  mg.  phosphate,  pot.  and  sod.  carbonate. 

Von  Hirt. 

12 

78 

Female 

Rectum 

Albumin,  NaCl,  K0SO4.  CaS04.  bile. 

Mayer. 

13 

19 

7 

Trs.  Colon 

Phosphates  of  Mg,  Ca,  K,  bile,  feces. 

Kothlein. 

14 

67 

Rectum 

"             '• 

Schmidt. 

15 

36 

31 

Male 

" 

Nucleus  of  cherry-stones,  feces,  inorganic  salts. 

Woehr. 

16 

68 

Ca,  K,  and  Mg  phosphates  and  sulphates. 

T  ran  be. 

17 

23 

Female 

Sigmoid 

Earthy  salts  and  bile-pigment. 

McDonald. 

18 

75 

*' 

" 

Dieger. 

19 

49 

Rectum 

Sod.  sulphate,  am.  and  Mg  phosphates,  Ca  salts. 

Le  Vale. 

20 

38 

61 

" 

Mineral  phosphates  and  carbonates. 

Behring. 

21 

43 

«* 

Unknown. 

Chaikovskj. 

22 

19 

64 

" 

Inorganic  salts,  cotton-fiber,  hair,  feces. 

Blunie. 

23 

1 

8 

Male 

Jejunum 

Bile-pigment,  feces,  amorphous  material. 

Hartse. 

24 

92 

Female 

Cecum 

ti               ..               ,.               t( 

Lichtenberg. 

25 

63 

Sigmoid 

Oat-husks,  feces,  bile-salts. 

McCurdy. 

26 

57 

" 

Rectum 

Nucleus  of  peach-stone,  bile,  feces. 

Hart. 

27 

29 

" 

Undetermined. 

Layers. 

28 

39 

Male 

" 

Largely  salts  of  Mg.  Bi,  and  K. 

Richardson. 

29 

74 

" 

Nucleus  of  calcined  bile,  periphery  of  petrified  fecal  ele- 
ments. 

Manley. 

30 

45 

Female 

" 

Not  stated. 

Boshe. 

31 

60 

" 

Feces,  hair,  inorganic  salts,  bile. 

Pollock. 

32 

43 

Male 

Trs.  Colon 

Pot.,  cal.,  and  ainmon.  phosphates  and  carbonates. 

Grant. 

33 

66 

Ileum 

Mineral  phosphates,  hair,  feces. 

Allen. 

34 

46 

Rectum 

*'               '*        *' 

35 

48 

Female 

Unknoivn. 

Jiieger. 

36 

49 

•' 

Bile-pigment,  cholesterin,  salts. 

Hammer. 

37 

81 

«' 

Starch,  fat,  cotton-fiber,  feces 

Garden. 

38 

42 

Male 

Des.  Colon 

Albumin.  NaCI,  Na2S04.  CaS04.  feces. 

Haussmaa. 

39 

14 

Female 

Sigmoid 

Nucleus  of  cherry-stones,  feces,  bile. 

Graf. 

40 
41 
42 

28 
62 
49 

Male 

Rectum 

Ammon  and  Mg  phosphate,  bile. 

Hut. 

'.i 

Phosphates,  carbonates,  IloO,  cholesterin. 

Martin. 

43 

16 

Female 

" 

Not  given. 

McDowell. 

44 

54 

Mineral  salts,  feces,  insol.  material. 

Bnicke. 

45 

52 

Sigmoid 

Calcium  phosphate  and  carbonate. 

Daniels. 

46 

6 

Male 

Rectum 

Undetermined. 

Coleman. 

47 

18 

Female 

Starch,  feces,  cholesterin.  fat. 

Moore. 

48 

74 

;;i 

Plum-stones,  inorganic  salts. 

Davis. 

49 

76 

" 

Undetermined. 

Halle. 

50 

24 

" 

•' 

Ammon.  and  Mg  phosphate,  calcium  salts. 

Thai  man. 

51 

50 

'* 

Fuller. 

52 

46 

" 

" 

Cholesterin  and  mineral  phosphates  and  carbonates. 

Gant. 

53 

3 

50 

Male 

" 

Bile-pigment,  cholesterin.  salts. 

54 

1 

43 

Female 

Phosphates,  lime,  magnesium,  and  ammonium  and  organic 
matter. 

In  order  to  form  some  idea  as  to  the  most  frequent  loca- 


ENTEROLITHS  AND  CONCRETIONS  643 

tion,  the  ages  at  which  they  occur  and  the  composition  of  en- 
teroHths,  the  author  has  tabulated  54  cases,  including  3  of  his 
own.  Of  this  number  35  were  women  and  19  men.  The  num- 
ber of  calculi  present  in  each  case  varied  from  one  to  thirty- 
eight.  Forty-one  had  but  one  stone  and  13  two  or  more. 
Their  ages  ranged  from  6  to  92  years.  Three  were  under  8, 
6  between  14  and  25,  4  between  25  and  40,  15  between  40  and 
50,  8  between  50  and  60,  9  between  60  and  70,  7  between  70 
and  80,  1  between  SO  and  90,  and  1  above  90,  the  average  age 
being  50  years. 

The  stones  were  located  in  every  part  of  the  intestine 
except  the  duodenum  and  ascending  colon.  They  were  in  the 
rectum  35  times,  in  the  sigmoid  in  5,  in  the  descending  colon  in 
1,  in  the  transverse  colon  in  2,  in  the  cecum  in  3,  in  the  ileum  in 
4,  and  in  the  jejunum  in  4.  The  most  surprising  and  interesting 
facts  brought  out  by  the  analysis  of  these  cases  are  that  the 
calculi  were  found  nine  times  in  persons  aged  25  years  or 
younger,  and  were  located  in  the  rectum  more  frequently  than 
in  all  other  parts  of  the  intestine,  showing  that  these  statistics 
differ  materially  from  those  of  other  writers. 


LITERATURE  ON  ENTEROLITHS  AND  INTESTINAL  CALCULI 


Aberle:  "Ein  Fall  von  Steinbildung,"  etc.,  Med.  Cor.  Bl.  d.  Wiirt.  Aerzt.  Yer., 
xxxviii,  1868. 

Adenstaedt :    "Ein  Fall  von  Darmsteine,"  Allg.  Med.  Zent.  BL,  xxx,  p.  121,  1861. 

Allingham:    "Diseases  of  the  Rectum,"  fifth  edition,  p.  24.     London,  1888. 

Andouard:    "Calc.  Intestin.,"  Jour,  de  Med.  de  r Quest.,  S.  iii,  p.  2,  Nantes,  1879. 

Ball;    "Diseases  of  the  Rectum  and  Anus,"  p.  391,  1887. 

Barker:  "Remarks  on  Intest.  Concr.,"  M.  and  Phys.  J.,  ii,  p.  292.  New  York, 
1821. 

Bellingham:  "On  the  Occurrence  of  Crystals  in  the  Human  Intest.,"  Jour.  Med. 
ScL,  xiv,  p.  278.     Dublin,  1838. 

Bennett:    "Alvine  Concretions,"  J.  M.  and  Ph.,  1,  p.  136.     Charleston,  1846, 

Boentler:    "A  Case  of  Intest.  Concr.,"  M.  J.  S.,  1,  p.  265.     Baltimore,  1830. 

Buchner:  "Darmsteine  beim  Menschen,"  Zeit.  f.  rat.  Med.,  x,  p.  191.  Heidel- 
berg, 1881. 

Bushe:    "Diseases  of  the  Rectum,"  p.  59,  1837. 

Butler:    "Calculus,"  etc.,  Prov.  M.  8.  and  J.,  v,  p.  507.    London,  1843. 

Cloquet:    "Mem.  sur  les  Concret.  Intest.,"  eighth  edition.     Paris,  1855. 

Cooper  and  Edwards:    "Intestinal  Concret.,"  "Diseases  of  Rectum,"  p.  304,  1892. 

Deaver:    "Rectal  Concretions,"  Med.  Times,  ix,  p.  239.    Philadelphia,  1879. 


644  DISEASES  OF  THE  RECTUM  AND  ANUS 

Dennis:    "System  of  Surgery,"  iv,  p.  299,  1896. 

D'Harveng:     "Cas   Remarquable  de  Calcul.   Intest.,"  Jour,  de  Med.,   Chir.,  et 

Pharm.,  xii.    Brux.,  1851. 
Evans:    "Obstruction  of  Bowels,"  etc.,  Assoc.  M.  J.,  i,  p.  395.     London,  1863. 
Fleckles:    "Hysterishes  Leiden,"  Allg.  Med.  Zent.  Zeit.,  xi,  p.  285.    Berlin,  1842. 
Gant:    Lecture,  New  York  Post-graduate  School  (unpublished),  Nov.  3,  1900. 
Graham:    "Case  of  Intest.  Calculus,"  etc.,  M.  8.  and  J.,  xxxiv,  p.  312.     Edin- 
burgh, 1830. 
Harriss:    "Case  of  Intest.  Calcul.,"  Jour.  Med.  Sci.,  vii,  p.  248.     Dublin,  1849. 
KhalofoflF:    "Annual  of  the  Universal  Medical  Sciences,"  iii,  p.  40, 
Leale:    "Intest.  Calculi,"  Med.  Record,  xvi,  p.  496.     New  York,  1879. 
Leichtenstern :    "Ziemssen's  Cyclop.  Med.,"  vii,  p.  577,  1876. 
Logerais:    "Obs.  de  Calcul.  Intest.,"  Gaz.  Hebd.  de  Med.,  2,  S.  xvii,  p.  354.    Paris, 

1880. 
Maclagan:    "Constitution  of  Concretions,"  London  and  Edinburgh  J.  M.  ScL, 

i,  p.  634,  1841. 
Manly   (Thomas  H.,  New  York)  :    Unpublished  case,  1896. 
Niemeyer:    "Practice  of  Medicine,"  1880. 
Osier:    "Practice  of  Medicine,"  p.  534,  1898. 
Pepper:    "System  of  Medicine,"  ii,  p.  844,  1894. 
Pratesi:    "Saggi  Chimici  Fatti  Sopra,  Alcuni  Calcoli  Intestinale,"  Lo  Spermi- 

mentali,  Firenzi,  xxvi,  pp.  156-9,  1870. 
Richie:    Month.  J.  M.  8ci.,  July,  1849. 
Riidiger:    "Beobach.  Einer  Intest.  Concret.,"  J.  f.  d.  Chir.  u.  Geb.,  p.  588.    Jena, 

1797. 
Schlossberg:     "Eigentiiml.    Concret.,"    Archiv    f.    Phys.    u.    Heillc,    vi,   p.    342. 

Stuttgart,  1847. 
Senn:    Trans.  Cong.  Amer.  Phys.  and  Surg.,  1888. 
Snape:    "Calculus,"  etc.,  Med.  Times,  vii,  p.  78.     London,  1878. 
Symonds:    "Alvine  Concret.  Syst.,"  "Tract.  Medic,"  iv,  p.  186.     Philadelphia, 

1841. 
Turner:    "Case  of  Intest.  Concr.,"  London  and  Edinburgh  J.  M.  Sci.,  i,  p.  630, 

1841. 
Virchow:    "Seltener  Darmstein  v.  Menschen,"  Archiv  f.  Path.  Anat.,  xx,  p.  403. 

Berlin,  1861. 
Von  Castell:    "Abgang.  Steinig.  Concret.  am  Mastdarme,"  Med.  Corr.  Bl.  Baier. 

Aerzte,  iii,  p.  129.    Erlangen,  1842. 
Watson:    "Intest.  Concret.,"  Edinburgh  Med.  Jour.,  xiii,  p.  987,  1868. 


CHAPTER  XXXVIII 

FOREIGN   BODIES,  WOUNDS,  AND  INJURIES 

The  proctologist  is  not  infrequently  called  upon  to  remove 
foreign  bodies  from  the  bowel  or  to  treat  wounds  and  injuries, 
slight  or  extensive,  of  the  rectum  and  anus. 

Foreign  bodies  in  the  rectum  may  be  grouped  into  three 
classes :  those  which  have  been  (a)  swallowed,  (h)  introduced 
through  the  anus,  or  (c)  formed  in  the  body. 

Foreign  bodies  which  have  been  szvalloived  are  encount- 
ered more  frequently  than  those  of  other  varieties.  They 
may  have  been  swallowed  accidentally  while  eating  or  drinking, 
and  numerous  cases  have  been  reported  where  fish  and  other 
bones  of  various  sizes  and  shapes,  pieces  of  gristle,  fruit-stones, 
etc.,  have  reached  the  rectum  in  this  manner.  The  author  on 
one  occasion  removed  from  the  rectum  a  large  triangular  piece 
of  a  chicken's  breast-bone  which  had  for  years  caused  partial 
obstruction,  great  pain,  and  frequent  hemorrhages.  He  has  in 
three  other  cases  successfully  removed  a  fish-bone  from  the 
anal  outlet.  It  is  not  a  rare  occurrence  for  persons  to  swallow 
whole  or  partial  sets  of  false  teeth,  and  these  are  not  infre- 
quently found  in  the  rectum.  Again,  children  while  playing 
have  swallowed  needles,  buttons,  safety-pins,  coins,  jackstones, 
thimbles,  cockle-burrs,  slate-pencils,  beads,  whistles,  rings,  and 
other  small  articles.  Dress-makers,  carpet-layers,  locksmiths, 
carpenters,  and  horseshoers  who  are  accustomed  to  hold  pins, 
tacks,  pieces  of  the  lock,  or  nails  in  the  mouth  while  at  work 
sometimes  swallow  them,  and  they  become  lodged  in  the  intes- 
tine. Customs-ofhcials  have  removed  precious  stones  from  the 
rectums  of  smugglers  who  had  swallowed  them  for  conceal- 
ment, and  travelers  have  also  been  known  to  swallow  small 
valuables  to  prevent  their  being  stolen.  Instances  have  been 
recorded  where  criminals  in  desperation  have  swallowed 
papers,  keys,  counterfeit  notes  and  coins,  and  other  incrimi- 
nating evidence  of  guilt.  It  is  not  uncommon  for  insane  per- 
sons to  swallow  hair,  pins,  needles,  spools,  thread,  spoons, 
knives,  forks,  jewelry,  plaster,  paper,  and  pieces  of  wood,  crock- 

(645) 


646  DISEASES  OF  THE  RECTUM  AND  ANUS 

ery,  or  glass :  in  fact,  any  small  object  obtainable  and  not  too 
large  to  be  swallowed.  In  many  cases  these  objects  have  been 
found  lodged  in  the  bowel. 

Foreign  bodies  have  been  extracted  from  the  rectum  or 
through  the  abdomen,  in  instances  in  which  they  had  been 
forcibly  introduced  through  the  anus  by  insane  persons,  rectal 
masturbators,  criminals  for  purposes  of  concealment,  persons 
suffering  from  constipation  who  attempt  to  stretch  the  anus 
in  this  manner,  and  by  pruritic  victims  who  are  in  the  habit 
of  scratching  the  parts  with  sticks,  stones,  etc.  Again,  rowdies, 
in  the  spirit  of  mischief,  have  been  known  to  force  objects  of 
various  kinds  and  sizes  into  the  rectums  of  sleeping  persons; 
and  robbers  have  resorted  to  this  means  of  disabling  their  vic- 
tims from  walking.  In  some  uncivilized  countries  prisoners  are 
punished  by  forcing  hot  clay  and  other  objects  of  torture  into 
the  rectum. 

Some  of  the  various  objects  which  have  been  removed 
from  the  rectum  after  forcible  introduction  through  the  anus 
are  sticks,  stones,  and  bottles  of  various  sizes  and  shapes ;  eat- 
ing utensils,  beer-glasses,  nails,  screws ;  knitting,  crocheting, 
and  darning  needles ;  keys,  spools  of  thread,  thimbles,  syringe- 
nozzles;  roher  bandages,  skeins  of  yarn,  pair  of  suspenders, 
lamp-chimneys,  potatoes,  radishes,  carrots,  turnips,  burglar's 
tools,  paper,  cloth,  jewelry,  pencils,  ferrules,  a  pig's  tail,  and 
other  articles  too  numerous  to  mention. 

In  this  respect,  a  most  interesting  case  was  reported  by 
Marchetti.  Some  students,  while  on  a  lark,  held  a  prostitute, 
and  introduced  into  her  rectum  all  except  the  small  extremity 
of  a  pig's  tail  the  bristles  of  which  had  been  cut  so  as  to  make 
it  as  rough  as  possible.  Various  attempts  to  remove  it  failed, 
owing  to  the  bristles  catching  in  the  mucous  membrane. 
Finally,  Marchetti  succeeded  in  slipping  a  cannula  over  it,  thus 
protecting  the  membrane,  when  it  was  removed  without  diffi- 
culty. 

Foreign  bodies  which  sometimes  form  in  the  body  and  be- 
come lodged  in  the  rectum  are,  in  the  order  of  their  frequency : 
coproliths,  gall-stones,  enteroliths  (Fig.  209),  avenoliths  (oat- 
stones),  pancreatic  calcuH,  urinary  calculi  (Fig.  210),  prostatic 
calculi,  and  bezoars  (hair  balls.  Fig.  208). 

Foreign  bodies  which  have  entered  the  rectum  and  re- 
mained there  for  a  considerable  time  may  serve  as  a  nucleus 


FOREIGN  BODIES,  WOUNDS,  AND  INJURIES 


617 


around  which  feces  or  earthy  salts  may  graduahy  collect  until 
the  mass  becomes  of  great  size ;  when  the  accumulation  is  due 
to  earthy  salts  the  concretion  usually  has  a  regular,  highly- 
polished  surface. 

Wounds  and  Injuries  of  the  rectum  are  comparatively  rare. 


Fig.  211. — Extensive  Sloughing,  including  Scrotum,  Buttocks,  etc.,  and  Recto- 
urethral  Fistula  Secondary  to  Extravasation  of  Urine  from  Rupture  of  tlie 
Urethra,  Caused  by  a  Fall  and  Direct  Violence  to  the  Perineum. 


They  occur  most  frequently  in  adult  life,  and  are  more  common 
in  women  than  in  men,  owing  to  parturition  and  the  fact  that 
women  so  often  suffer  from  constipation.  Cases  have  been 
recorded  in  which  the  recto-vaginal  septum,  perineum,  and  rec- 
tum were  lacerated  during  labor,  and  other  cases  have  been  ob- 


648  DISEASES  OF  THE  RECTUM  AND  ANUS 

served  in  which  ulceration,  sloughing,  abscess,  and  fistula  have 
occurred  as  the  result  of  injury  to  the  blood-vessels  by  the 
passage  of  the  child's  head.  Constipation  compHcated  by  fecal 
impaction  is  a  fruitful  source  of  injury  to  the  rectum.  When 
comparatively  small  and  nodular  the  fecal  masses  may  produce 
longitudinal  rents  in  the  mucosa  (fissure)  during  expulsion; 
when  the  accumulation  assumes  enormous  proportions,  it  may 
cause  rupture  of  the  bowel,  involving  all  the  coats  as  a  result 
of  distension  and  straining.  Rupture  of  the  rectum  has  also 
been  produced  by  inserting  the  whole  hand  into  the  bowel, 
overdistension  with  water  or  medicated  fluids,  careless  intro- 
duction of  the  colon-tube  and  bougies,  and  by  foreign  bodies. 
The  author  once  treated  a  man  who  had  been  thrown  from  his 
buggy  upon  a  snag,  sustaining  extensive  laceration  of  the  peri- 
neum, rectum,  and  urethra.  Escape  of  urine  into  the  tissues 
caused  extensive  sloughing,  followed  by  recto-urethral  fistula. 
Another  of  the  author's  patients  was  a  boy  of  12  who  had  fallen 
out  of  a  cherry-tree  and  been  impaled  on  a  picket-fence,  pro- 
ducing similar  injuries  (Fig.  211).  A  third  case  of  severe  injury 
to  the  rectum  treated  by  the  author  was  that  of  a  burglar  who, 
while  climbing  a  fence  to  escape,  had  been  shot  by  a  policeman. 
The  ball  entered  the  anus,  passed  through  the  rectum  about 
three  inches  above,  and  came  out  in  the  right  groin.  All  of 
these  cases  recovered. 

Other  sources  of  injury  to  the  rectum  are  kicks,  falls,  stab 
wounds,  pederasty,  careless  introduction  of  the  syringe-nozzle 
in  giving  enemata ;  operations  upon  the  bladder,  urethra,  pros- 
tate, seminal  vesicles,  uterus,  vagina,  sacrum,  and  coccyx ;  and 
rough  and  rapid  divulsion  of  the  anus,  especially  with  mechanic 
dilators. 

SYMPTOMS 

The  symptoms  induced  by  foreign  bodies  in  the  rectum  de- 
pend upon  the  number,  consistence,  size,  and  shape  of  such 
objects ;  the  force  used  in  introducing  them,  their  location,  and 
the  length  of  time  they  have  been  lodged  in  the  bowel.  When 
sharp  or  angular,  they  frequently  cause  acute  pain  and  exten- 
sive hemorrhages.  If  the  rectal  wall  is  injured,  peritonitis, 
abscess,  and  simple  recto-urethral,  recto-vaginal,  or  recto- 
vesical fistulas  may  result.  If  large  and  smooth,  and  ovoid  or 
elongated  in  shape,  they  produce  hemorrhages,  local  or  reflex 


FOREIGN  BODIES,  WOUNDS,  AND  INJURIES  649 

pain,  constipation,  tympanites,  abdominal  tenderness,  and 
fecaloid  vomiting :  in  fact,  all  the  symptoms  of  obstruction. 
Owing  to  the  pressure  thus  caused,  extensive  ulceration,  gan- 
grene, and  sloughing  may  result.  When  small  and  of  any 
shape,  they  cause  local  pain,  tenesmus,  straining,  more  or  less 
bleeding,  frequent  discharge  of  mucus  and  pus,  and  sometimes 
prolapse.  As  a  result  of  injury  to  the  mucosa  and  subsequent 
infection,  abscess  and  fistula  are  sometimes  excited  by  the 
presence  of  foreign  bodies.  In  cases  where  a  foreign  body  is 
suspected,  little  information  is  to  be  obtained  from  the  patient, 
because  he  is  either  unaware  of  its  presence  or,  if  aware  of  it, 
ashamed  to  disclose  the  manner  of  its  introduction.  For  this 
reason  a  diagnosis  is  dilificult  unless  the  body  protrudes  from 
the  anus  or  is  so  located  as  to  be  felt  with  the  finger  or  seen 
through  the  speculum  or  colon-tube,  or  by  aid  of  the  procto- 
scope and  rectal  inflation.  When  the  foreign  body  has  been 
carried  high  up  into  the  abdomen,  exploratory  laparotomy  is 
necessary. 

The  symptoms  of  wounds  and  injuries  of  the  rectum  do  not 
dififer  from  those  in  other  parts  of  the  body  except  when  the 
urethra  or  bladder  is  involved,  in  which  instance  there  may  be 
concealed  hemorrhage,  extravasation  of  urine,  and  consequent 
sloughing  (Fig.  211),  followed  by  abscess  and  fistula.  When 
the  wound  extends  sufficiently  high  to  injure  the  peritoneum, 
death  may  ensue  from  peritonitis. 

TREATMENT 

The  manner  of  extracting  foreign  bodies  which  cannot  be  ex- 
pelled from  the  rectum  must  be  varied  to  suit  the  case.  In 
most  instances  they  are  of  such  size  and  so  situated  that  they 
can  be  removed  with  the  fingers  or  the  author's  strong  forceps 
(Fig.  172).  When  a  small  sharp,  irregular  object  has  been  swal- 
lowed, the  patient  should  be  requested  to  eat  corn-bread,  pota- 
toes, and  similar  foods  which  form  coarse,  thick  feces,  in  which 
the  foreign  body  is  most  likely  to  be  incorporated.  When  they 
are  too  large  to  be  delivered  through  the  anus,  or  have  become 
imbedded,  an  anesthetic  should  be  given  and  the  sphincter 
divulsed  sufficiently  to  allow  removal  of  the  body  with  fingers 
or  by  careful  dissection.  If  dilatation  does  not  give  sufficient 
room,  the  lower  rectum  should  be  split  posteriorly  down  to  the 
coccyx  and  the  wound  closed  after  the  body  has  been  removed. 


650  DISEASES  OF  THE  RECTUM  AND  ANUS 

Wooden  objects  may  be  removed  by  means  of  a  screw  or  gim- 
let ;  when  of  glass  they  must  be  handled  with  exceeding  care : 
otherwise  they  may  be  broken,  and  cause  alarming  hemorrhage 
from  laceration  of  the  parts.  When  of  wire  or  metal,  they  may 
be  divided  with  nippers  if  necessary,  and  then  removed  in  sec- 
tions. When  the  offending  body  is  pointed  or  angular,  every 
precaution  should  be  taken  to  protect  the  mucosa  from  injury. 
After  the  foreign  body  has  been  removed  from  the  rectum,  the 
abrasions  should  be  kept  cleaned,  stimulated,  and  allowed  to 
heal  by  granulation. 

Wounds  and  injuries  of  the  rectum  should  be  treated  in  the 
same  manner  as  similar  wounds  and  injuries  in  other  parts  of 
the  body.  Clean-cut  and  lacerated  wounds,  the  edges  of  which 
can  be  trimmed  and  approximated,  should  be  thoroughly 
cleansed  and  closed  with  catgut  under  aseptic  conditions. 
Deep,  extensive,  and  irregular  tears  and  lacerations  should  be 
treated  by  ligation  of  all  spurting  vessels,  thorough  cleansing 
and  packing  the  wound  with  gauze,  and  allowing  it  to  heal  by 
granulation,  the  same  as  in  fistula  operations.  When  there  is 
a  rent  in  the  bladder,  vagina,  or  urethra,  it  should  be  closed 
immediately  with  fine  catgut,  or,  if  this  is  impossible,  allowed 
to  heal  by  granulation. 


ILLTISTRATIVE   CASE 

Case  XLIII.  Stick  in  the  Rectum;  Death  from  Peritonitis. — A  few 
years  since  one  of  my  former  pupils,  Dr.  Hawthorne,  of  Hiawatha,  Kansas, 
presented  me  with  a  stick  which  he  had  removed  from  the  rectum  of  a  gen- 
tleman who  died  from  peritonitis  several  hours  after  operation.  He  gave  me 
the  following  history  of  the  case:  He  had  been  called  hurriedly  on  the  after- 
noon of  September  1,  1893,  to  see  Mr.  B.,  of  Kansas,  aged  about  65  years. 
He  found  the  patient  suffering  excruciating  pain,  caused  by  a  large  stick, 
which  was  projecting  from  his  anus.  The  patient  informed  the  doctor  that 
for  a  number  of  years  he  had  been  afflicted  with  very  annoying  itching  about 
the  anus,  which  was  increased  every  time  the  bowels  moved.  To  obtain  tem- 
porary relief  he  had  been  in  the  habit  of  taking  a  chip  or  stick  and  scratching 
himself.  On  this  particular  occasion  he  had  selected  a  very  knotty  stick 
about  an  inch  (2.54  centimeters)  in  diameter  and  about  ten  inches  (2.5 
decimeters)  in  length  (Fig.  212),  which  had  a  hook  about  two  inches  (5  centi- 
meters) from  the  end.  With  this  he  was  enjoying  the  luxuries  of  a  good 
scratch  when  his  feet  slipped  from  under  him  and  the  stick  came  in  contact 
with  the  ground,  and  was  forced  into  the  rectum  for  about  two  inches  (5 
centimeters).  An  attempt  was  made  to  withdraw  it,  but  he  was  unable  to 
do    so,   for   the   hook   had   caught   in   a   fold   of  the   mucous   membrane.     He 


FOREIGN  BODIES,  WOUNDS,  AND  INJOTIIES 


651 


endeavored  to  release  it  by  pushing  it 
farther  up  the  bowel  and  then  withdrawing 
it,  but  it  became  fastened  again;  he  made 
several  futile  attempts,  the  stick  each  time 
going  higher  up  the  bowel.  In  despair  he 
called  his  wife  and  son,  who  carried  him  to 
the  house  and  placed  him  in  bed.  His  son 
then  tried  to  remove  the  stick  by  force, 
causing  much  pain  and  bleeding.  Finally 
he  became  frightened  and  Dr.  Hawthorne 
was  called  in.  On  examination  it  was  found 
that  the  hooked  portion  of  the  stick  had 
caught  in  the  posterior  wall  of  the  rectum 
about  six  inches  (15  centimeters)  above  the 
anus.  It  was  pushed  upward  until  the  point 
of  the  hook  was  released;  the  sharp  point 
was  then  covered  by  the  finger  and  the  stick 
withdrawn  without  further  difficulty.  This, 
of  course,  was  done  under  an  anesthetic,  as 
it  was  necessary  to  force  the  hand  partly 
into  the  rectimi.  There  was  considerable 
bleeding,  and  a  rent  was  found  through  the 
peritoneum  about  three  inches  (7.5  centi- 
meters) in  length.  A  consultation  was  ad- 
vised, and  Dr.  E.  W.  Baird,  of  Tescot,  Kan- 
sas, was  called.  It  was  thought  best  to 
keep  the  rectum  clean  by  antiseptic  irriga- 
tions and  the  bowel  quiet  by  the  use  of 
large  doses  of  morphine,  and  to  allow  Na- 
ture a  chance  to  heal  up  the  rent.  The  pa- 
tient continued  to  grow  worse.  The  tem- 
perature was  high,  the  pulse  very  fast  and 
thread-like,  the  pain  increased  in  severity, 
and  the  abdomen  rapidly  distended  with  gas 
until  it  was  almost  as  tense  as  a  drum- 
head. He  became  unconscious,  and  thirty- 
six  hours  from  the  time  the  stick  was 
forced  into  the  rectum  he  died  from  peri- 
tonitis. 

This  case  is  another  example  where  a 
life  was  sacrificed  by  the  laity  in  trying  to 
avoid  payment  of  a  surgeon's  fee.  Had  Dr. 
Hawthorne  been  called  when  the  accident 
first  occurred,  there  is  not  much  question 
but  that  the  stick  could  have  been  removed 
without  serious  injury  to  the  bowel. 


■^S 


fc>I 


Fig.  212.— Stick  Removed  from 
the  Rectum  (Half-size). 


652  DISEASES  OF  THE  RECTUM  AND  ANUS 

LITERATTTRE  ON  FOREIGN  BODIES  IN,  AND  WOUNDS  AND 
INJURIES  OF,  THE  RECTUM 


Allingham :    "Diseases  of  the  Rectum  and  Anus,"  fifth  edition,  p.  241,  1888. 
Ashton:    "Foreign  Bodies  in  the  Rectum,"  "Diseases  of  the  Rectum  and  Anus," 

p.  310,  1854, 
Ball:    "The  Rectum  and  Anus,"  p.  390,  1887. 
Cooper  and  Edwards:    "Diseases  of  the  Rectum  and  Anus,"  second  edition,  p. 

303,  1892. 
Dahllenkampf:    Heidelberg  klin.  Annalen,  1829. 
Desormeaux:    Bull.  Soc.  de  Gliir.,  Feb.,  1862. 
Gant:    "Diseases  of  the  Rectum  and  Anus,"  p.  366,  1896. 
Hamilton:    "A  New  Account  of  the  East  Indies."     London,  1708. 
Kelsey:    "Diseases  of  the  Rectum  and  Anus,"  third  edition,  p.  459,  1890. 
Laure:    Gaz.  Medicate  de  Lyon,  1868. 
Liston:    "Pract.  Surgery,"  fourth  edition,  p.  431,  1846. 
Marchetti:    "Obs.  Med.-Chir.  Rarior  Syllog.,"  cap.  vii,  1665. 
Moraud:    Mem.  de  I'Acad.  Royale  de  Chir.    Paris,  1700. 
Nelaton:    "Pathol.  Chir.,"  tome  v,  p.  41,  1858. 
Phillips:    Medical  Gazette,  vol.  xxix,  p.  846,  1842. 
Pilcher:    Lancet   (London),  vol.  i,  p.  23,  1866. 
Pollock:    Med.  Presse,  1869. 

Poulet:    Archives  Gen.  de  Med.,  fourth  series,  tome  xxi,  1849. 
Realli:    Gaz.  Med.,  Paris,  July,  1851. 
Studsgaard:    "Soc.  de  Chir.,"  p.  662,  1878. 
Thiandiere:    Bull.  Gen.  de  Therap.,  Jan.,  1835. 
Thomas:    Med.-Chir.  Trans.,  vol.  i,  1807. 

Van  Buren:    "Lectures  upon  Diseases  of  the  Rectum  and  Anus,"  p.  384,  1882. 
Velpeau:    Gaz.  Med.  de  Paris,  p.  684,  1849. 
Weigand:    Schmidt's  Annalen,  vol.  iv,  p.  95,  1862. 


CHAPTER  XXXIX 

SODOMYi  (PEDERASTY^)  AND  RECTAL  ONANISM 
(RECTAL  MASTURBATION) 

The  term  sodomy  is  used  to  express  unnatural  intercourse 
(abuse)  in  a  variety  of  ways.  At  times  it  is  used  to  designate 
intercourse  between  some  animal  and  a  man  or  a  woman  (bes- 
tiality) ;  or,  on  the  other  hand,  between  man  and  man,  man 
and  boy,  and  between  man  and  woman  where  the  male  organ  is 
introduced  into  the  rectum  for  the  purpose  of  gratifying  sexual 
appetite.  When  of  the  latter  variety, — that  is,  when  the  penis 
is  introduced  per  rectum, — it  is  called  by  a  different  name: 
"pederasty." 

Pederasty,  in  its  strictest  sense,  means  intercourse  with  a 
boy  per  anum.  In  a  broad  sense,  it  is  applied  to  unnatural 
sexual  intercourse  between  male  and  male  and  between  male 
and  female  at  any  age.  This  subject  is  approached  with  con- 
siderable diffidence,  because  topics  of  this  nature  are  revolting 
to  the  educated  and  refined  mind.  There  are,  however,  so 
many  diseases  about  the  rectum  and  anus  contracted  during 
such  acts  or  occurring  as  a  direct  result  of  the  same  that  a 
slight  discussion  is  justifiable.  But  one  variety  of  sodomy — 
namely,  pederasty — will  be  considered,  for  the  reason  that  the 
study  of  the  unnatural  relations  which  may  exist  between  man 
and  beast  would  be  out  of  place  in  a  work  of  this  kind.  The 
author  has  not  met  with  more  than  a  dozen  pederasts  in  his 
entire  practice,  and  it  is  with  much  pleasure  that  he  records 
the  fact  that  Americans  resort  to  this  mode  of  sexual  gratifica- 
tion less  frequently  than  individuals  of  any  other  nationality. 
Though  the  literature  be  searched  for  reports  of  such  cases 
occurring  in  this  country,  but  few  will  be  found  in  comparison 
to  the  large  number  recorded  by  writers  upon  this  subject  as 
occurring  in  other  countries.  In  the  United  States,  pederasts 
are  found  principally  among  sailors,  soldiers,  miners  in  the  far 
West,  and  sometimes  among  farm-hands  in  the  rural  districts 
where  there  are  no  prostitutes  to  satisfy  their  sexual  desires. 

The  author  has  been  reliably  informed  that  in  the  lower 

1  26so/xa  =  Sodom,  an  ancient  city  of  Asia. 

2  iraii  =  boy  ;  ipdoiv  =  to  love. 

(653) 


654  DISEASES  OF  THE  EECTUM  AND  ANUS 

east  side  of  the  city  of  New  York  there  did  exist  a  small  colony 
of  sexual  perverts  of  this  type,  many  of  whom  formerly  held 
high  social  positions.  The  members  of  this  band  had  a  theatre 
coinique,  where  they  performed  and  had  their  exclusive  dances; 
they  also  "paired  off,"  and  lived  together  as  husband  and  wife. 
The  author  has  personal  knowledge  of  but  a  single  instance  where 
an  individual  was  detected  in  this  act  by  the  authorities, 
namely:  that  of  a  negro  boy  18  years  old.  He  was  convicted 
and  sent  to  the  State  penitentiary  for  a  term  of  five  years. 

This  vice  is  so  common  in  some  countries — China,  Asia, 
France,  Germany,  and  Austria — that  most  rigid  laws  have  been 
enacted  to  suppress  it.  French  writers  tell  us,  however,  that, 
in  spite  of  these  precautions,  pederasts  are  increasing  in  num- 
ber every  year.  It  is  said  that  they  have  meeting-places  and 
frequently  congregate  in  large  numbers  in  the  same  flat  or 
neighborhood,  and  that  in  Paris  it  is  not  uncommon  for  pro- 
fessional pederasts  (male  prostitutes)  to  walk  the  streets  in 
search  of  those  who  would  gratify  themselves  by  indulgence 
in  this  nefarious  practice.  It  is  further  stated  that  they  readily 
recognize  each  other  by  their  actions  and  manner  of  dress,  the 
passive  pederast  alwa3^s  simulating  femininity. 

To  show  the  large  number  of  pederasts  in  France  and  the 
ph3'sical  signs  by  which  they  can  be  detected,  the  author  will 
quote  from  an  elaborate  paper  by  Tardieu.^  During  attempts 
made  by  the  police  to  suppress  pederasty  in  Paris  this  authority 
had  the  opportunity  of  examining  on  one  occasion  97  and  on 
another  52  persons  taken  in  the  act.  He  also  visited  60  others 
at  different  times,  besides  examining  many  dead  bodies  of  per- 
sons on  whom  this  crime  had  been  committed.  With  regard 
to  their  ages  and  occupations  he  gives  the  following  statis- 
tics : — - 

Taedieu's  Statistics  Regarding  the  Ages   and 
Occupations  of  Pederasts 

Occupation.  Number. 

Servants    44 

Merchants'  clerks   29 

Tailors  12 

Military  men   12 

Others  belonging  to  59  different  occupations.  .  .    108 


'  Ziemssen's  "Cyclopedia,"  xix,  p.  53,  1876. 


Table   XXVI. 

Tai 

Age. 

Number. 

12  to  15  years 

13 

15  to  25       " 

65 

25  to  35       " 

26 

35  to  45       " 

28 

45  to  55       " 

18 

65  to  75       " 

4 

Not  given 

.46 

SODOMY  AND  RECTAL  ONANISM  655 

Casper  maintains  that  persons  may.be  pederasts  of  long 
standing  and  show  no  signs  of  it;  but  Tardieu  states  that,  out 
of  205  avowed  pederasts,  he  found  only  14  in  whom  it  was  im- 
possible to  detect  any  trace  of  this  practice.  Out  of  this  num- 
ber, those  whose  habits  were  passive  numbered  99 ;  and  those 
with  habits  exclusively  active,  18 ;  both  active  and  passive,  71 ; 
not  given,  17. 

With  this  immense  experience  he  makes  the  following  ob- 
servations as  to  the  effects  of  this  peculiar  sexual  perversion : — 

Physical  Signs. — Passive  pederasty  produces  excessive  de- 
velopment of  the  buttocks,  an  infundibuliform  appearance  of 
the  anus,  relaxed  sphincter,  effacement  of  the  anal  folds,  car- 
unculse  of  the  orifice,  incontinence  of  feces,  ulcerations,  fissures, 
and  so  forth. 

The  infundibuliform  anus  has  generally  been  considered 
a  pathognomonic  sign.  It  is  not  always  present,  however; 
but  was  found  100  times  in  170  cases.  It  may  be  absent  in 
persons  with  very  fat  or  very  thin  buttocks.  He  believes  the 
relaxation  of  the  sphincter  to  be  fully  as  true  and  characteristic 
a  sign  of  pederasty  as  is  the  funnel-shaped  anus.  He  found  this 
in  110  out  of  170  cases. 

The  natural  folds  and  puckers  are  effaced  and  the  anus 
is  smooth  and  polished :  the  podex  IcFvis  of  the  Romans.  The 
stretching  and  use  of  emollients  to  facilitate  intromission  cause 
relaxation  of  the  tissues  to  such  an  extent  as  to  produce  a  sort 
of  prolapse  of  the  mucous  membrane ;  so  that  in  some  cases 
it  may  resemble  the  labia  minora- of  the  female. 

In  active  pederasts  the  penis  is  usually  very  small  or  very 
large. 

The  large  penis  is  rare,  but  in  all  cases  the  dimensions  of 
the  organ  are  excessive  in  one  sense  or  the  other:  i.e.,  of  the 
organ  when  not  in  a  state  of  erection.  Its  form  is  ver}^  char- 
acteristic. When  small  and  thin,  it  diminishes  toward  the  glans, 
which  is  quite  small ;  so  that  the  penis  resembles  that  of  a  dog. 
This  is  the  most  common  shape,  and  suggests  the  idea  that  the 
tendency  of  some  individuals  toward  this  unnatural  vice  may 
be  due  to  an  incapacity  for  ordinary  sexual  intercourse. 

When  the  penis  is  voluminous,  the  whole  organ  does  not 
taper.  The  glans  only  is  elongated,  and  the  penis  is  twisted 
upon  itself  so  that  the  meatus  is  directed  obliquely  toward  the 
right  or  the  left.     This  distortion  is  sometimes  very  marked. 


656  DISEASES  OF  THE  RECTUM  AND  ANUS 

and  appears  more  pronounced  as  the  dimensions  of  ihe  organ 
increase. 

It  now  remains  to  be  shown  how  these  miserable  mortals 
sink  so  low  in  the  social  scale  as  to  become  habitues  of  this 
abominable  practice,  and  why,  when  once  the  habit  is  formed, 
it  is  seldom  given  up.  To  do  this  it  is  necessary  to  define  active 
and  passive  pederasty.  The  person  who  introduces  the  male 
organ  is  called  an  active,  and  the  one  who  receives  it  a  passive, 
pederast. 

The  different  ways  by  which  pederasty  is  acquired  are  best 
described  by  von  Krafft-Ebing,  as  follows^ ; — 

Active  pederasty  occurs : — 

1.  As  a  non-pathologic  phenomenon : — 

"(a)  As  a  means  of  sexual  gratification,  in  cases  of  great 
sexual  desire,  with  enforced  abstinence  from  sexual  intercourse. 

''(h)  In  old  debauchees,  who  have  become  satiated  with 
normal  sexual  intercourse  and  are  more  or  less  impotent,  and 
also  morally  depraved,  and  who  resort  to  pederasty  in  order 
to  excite  their  lust  with  this  new  stimulus,  and  aid  their  viriHty, 
that  has  sunk  so  low  psychically  and  physically. 

''(c)  Traditionally,  among  certain  barbarous  races  that 
are  devoid  of  morality." 

2.  As  a  pathologic  phenomenon : — 

"  (a)  Upon  the  basis  of  congenital  contrary  sexual  instinct, 
with  repugnance  for  sexual  intercourse  with  women,  or  even 
absolute  incapability  of  it.  But,  as  even  Casper  knew,  peder- 
asty under  such  conditions  is  very  infrequent.  The  so-called 
urning  satisfies  himself  with  a  man  by  means  of  a  passive  or 
mutual  onanism  or  by  means  of  coitus-like  acts  (coitus  inter 
femora);  and  he  resorts  to  pederasty  only  very  exceptionally, 
as  a  result  of  intense  sexual  desire,  or  with  a  low  or  lowered 
moral  sense,  out  of  a  desire  to  please  another. 

"(h)  On  the  basis  of  acquired  contrary  sexual  instinct,  as 
a  result  of  long  years  of  onanism  (masturbation),  which  finally 
causes  impotence  for  women  with  continuance  of  intense  sex- 
ual desire.  Also  as  a  result  of  severe  mental  disease  (senile 
dementia,  brain-softening  of  the  insane,  etc.),  in  which,  as  ex- 


1  "Psychopathia    Sexualis,"    Krafft-Ebing    (Chaddock),    American,    from    Beventb 
German,  edition,  p.  42S,  1893. 


SODOMY  AND  RECTAL  ONANISM  657 

perience  teaches,  an  inversion  of  the  sexual  instinct  may  take 
place." 

Passive  pederasty  occurs : — 

1.  As  a  non-pathologic  phenomenon: — 

"(a)  Individuals  of  the  lowest  class  who,  having  had  the 
misfortune  to  be  seduced  in  boyhood  by  debauchees,  endured 
pain  and  disgust  for  the  sake  of  money  and  became  depraved 
morally;  so  that,  in  more  mature  years,  they  have  fallen  so  low 
that  they  take  pleasure  in  being  male  prostitutes. 

"(b)  Under  circumstances  analogous  to  the  preceding,  as 
a  remuneration  to  another  for  having  ahowed  active  peder- 
asty." 

2.  As  a  pathologic  phenomenon : — 

"(a)  In  individuals  afl'ected  with  contrary  sexual  instinct, 
with  endurance  of  pain  and  disgust,  as  a  return  to  men  for  the 
bestowal  of  sexual  favors. 

"(b)  In  urnings  who  feel  toward  men  like  women,  out  of 
desire  and  lust.  In  such  effeminate  men  there  is  a  horror  femincu 
and  absolute  incapability  for  sexual  intercourse  with  women. 
Their  character  and  inclinations  are  feminine." 

This  classification  is  said  to  include  all  the  empiric  facts 
that  have  been  gathered  by  legal  medicine  and  psychiatry. 

With  this  understanding  of  how  these  people  become 
pederasts,  it  is  now  in  order  to  discuss  the  diseases  about  the 
rectum  and  anus  that  may  result  from  this  practice.  They  are 
many,  because  the  pederast  may  contract  in  the  ano-rectal 
region  all  of  the  diseases  common  to  the  genitals  of  the  ordinary 
prostitute. 

Any  one  of  the  following  pathologic  conditions  may  be 
present  as  a  result  of  intercourse  per  rectum,  some  produced 
as  a  result  of  direct  contact ;   others,  by  secondary  infection : — 

1.  Hard  chancre.  7.  Condylomata  (syphilitic 

2.  Soft     chancre      (phage-  or  gonorrheal). 

denic  or  otherwise).  8.   Fistula. 

3.  Proctitis  (simple  or  gon-        9.   Lacerations    and    abra- 

orrheal).  sions. 

4.  Ulceration.  10.  Incontinence. 

5.  Fissures.  11.  Ecchymoses. 

6.  Abscess.  12.  Deformity  of  the  anus. 

13.  Procidentia  recti. 

42 


658  DISEASES  OF  THE  RECTUM  AND  ANUS 

No  attempt  will  be  made  to  outline  the  treatment  of  these 
diseases  in  this  connection,  for  the  reason  that  it  has  been  given 
in  detail  in  other  chapters.  There  is  one  other  habit  through 
which  diseased  conditions  about  the  rectum  and  anus  are  some- 
times produced, — that  of  rectal  onanism  (masturbation). 

RECTAL   ONANISM 

Rectal  masturbation  is  sometimes  resorted  to  by  those 
who,  for  various  reasons,  are  not  permitted  to  have  normal  in- 
tercourse. It  is  more  frequently  practiced,  however,  by  men 
who,  for  some  cause,  have  lost  their  sexual  power  and  can- 
not obtain  satisfaction  in  the  natural  way.  That  sexual  orgasm 
may  be  excited  in  this  way  there  is  little  room  to  doubt. 
If  such  were  not  the  case  these  people  would  not  submit  more 
than  once  to  the  pain  and  disgust  that  at  first  must  accompany 
the  act.  On  the  contrary,  it  is  a  noted  fact  that,  when  once 
this  habit  has  been  established,  its  victims  seldom  have  sufficient 
will-power  to  stop  it.  That  some  sexual  gratification  is  secured 
from  this  practice  is  shown  by  the  actions  of  passive  pederasts, 
who  are  neither  forced  nor  paid  to  submit  to  the  active  party, 
but,  on  the  contrary,  seek  those  who  will  satisfy  their  lust,  and, 
if  necessary,  recompense  them  for  assuming  the  active  part. 
The  instruments  used  ordinarily  in  rectal  masturbation  are  the 
fingers,  candles,  bottles,  walking-sticks,  rectal  bougies,  or,,  in 
fact,  any  smooth  object  which  can  be  introduced  into  the  rec- 
tum to  excite  sexual  orgasm. 

There  are  many  pathologic  conditions  which  may  be  pro- 
duced in  and  about  the  rectum  by  this  practice ;  the  most  com- 
mon are  eccJiymoses,  injuries  to  the  mucous  membrane,  weak- 
ening or  destruction  of  the  sphincter-muscle,  prolapse,  fissures,  tdcer- 
ation,  and  proctitis.  In  old  habitues  the  mucous  membrane, 
because  of  ulceration  and  inflammation,  becomes  very  much 
thickened,  glistening,  and  of  parchment-like  appearance. 

For  the  treatment  of  these  conditions  the  reader  is  referred 
to  other  chapters  of  this  book. 


LITERATURE  ON  PEDERASTY   (SODOMY) 

Bird:    "Impersonation  of  a  Woman,"  Med.  Record,  New  York,  xlix,  500,  1896. 
Crombie:    "A  "Remarkable  Case  of  Sodomy."  Indian  Med.  Gaz.,  Calcutta,  xiv, 
104,  1889. 


SODOMY  AND  RECTAL  ONANISM  659 

Dufour:    "Histoire  de  la  prostitution  chez  tous  les  peuples,"  etc.     Paris,  1851. 
Howard:    "Pederasty  vs.  Prostitution,"  etc.,  Jour.  Amer.  Med.  Assoc,  xxviii, 

p.  930,  1897. 
lirafft-Ebing :    "Psychopathia  Sexualis"   (Chaddock),  American,  from  seventh 

German,  edition,  p.  426,  1893.     F.  A.  Davis  Company,  Philadelphia. 
Martineau:     "Legons   sur  les  deformations  vulvaires   et  anales,"   etc.,   second 

edition.     Paris,  1886. 
Matignon:    "Du  mots  sur  la  pederastie  en  Chine,"  Archives  d'anthrop.  Crimi- 

nelle,  xiv,  pp.  38,  53.     Lyons  and  Paris,  1899. 
Montane:    "La  Pederastie  en  Cuba,"  Cong.  Med.  region  de  Cuba,  Habana,  578- 

590,  1890. 
Raynold:    "Perversion  du  sens  genital,"  Jour,  de  Med.  de  Paris,  x,  236,  1898. 
Scarenzio:    "Caso  dli  manusturpazione  pederastica,"  Gaz.  Med.  Ital.  Lonii.,  ii, 

325.     Milano,  1863. 
Schools:    "Sur  un  cas  de  pederastie,"  Revue  de  Med.  Leg.,  ii,  101-104.     Paris, 

1895. 
Tardieu:    Ziemssen's  "Cyclopedia,"  xix,  p.  53,  1876. 
Thiry:    "Rectite  blennorrhagique,"  Presse  Med.  Belg.,  xxxiv,  201-203.     Brux., 

1882. 
Weiss:    "Ein  Fall  van  Athetose;   Paderastie,"  etc.,  Wiener  med.  Presse,  xxv, 

1312-1314,  1894. 
Winslow:    "Report  of  an  Epidemic  of  Gonorrhoea  Contracted,"  etc.,  Med.  News, 

xlix,  180.    Philadelphia,  188€. 


CHAPTER  XL 

RAILROADING  AS  AN  ETIOLOQIC  FACTOR  IN  RECTAL 

DISEASE 

This  topic  is  one  of  unusual  importance,  and  should  enlist 
the  interest,  not  only  of  the  proctologist,  but  also  of  all  sur- 
geons, and  especially  those  engaged  in  railway  surgery. 

So  far  as  the  author  has  been  able  to  learn,  railroading  as 
an  etiologic  factor  in  rectal  disease  has  never  been  mentioned  in 
any  previous  work. 

In  order  to  demonstrate  that  railroading  predisposes  con- 
ductors, engineers,  firemen,  porters,  brakemen,  baggagemen, 
and  mail-clerks  to  many  of  the  diseases  common  to  the  ano- 
rectal region,  the  author  will  not  confine  himself  entirely  to 
his  personal  experience  in  handling  these  cases  in  railway  hos- 
pitals, but  will  also  give  the  opinion  and  statistics  of  other  sur- 
geons connected  with  similar  institutions. 

In  the  past  it  has  been  the  author's  privilege  to  treat  many 
hundreds  of  railway  employees  for  a  variety  of  rectal  diseases. 
Several  years  ago  it  occurred  to  him  that  perhaps  the  occupation 
of  tliese  men  was  in  some  way  responsible  for  the  annoying  con- 
ditions so  frequently  met  with  about  the  terminal  colon.  Work- 
ing along  this  line,  he  has  devoted  much  thought  to  the  subject, 
and  made  extensive  inquiries  of  both  railway  surgeons  and 
employees  with  the  view  of  ascertaining  what  proportion  of  rail- 
road men  suffer  from  rectal  disease. 

The  investigation  proved  conclusively  that  their  vocation 
plays  an  important  role  in  the  production  of  these  diseases,  and, 
furthermore,  that  fully  75  per  cent,  of  all  railway  employees 
who  have  been  traveling  on  trains  for  a  term  of  five  years  or 
more  suffer  or  have  suffered  from  some  disease  about  the  rec- 
tum or  anus.  Dr.  W.  P.  King,  assistant  chief-surgeon  of 
the  Missouri  Railroad  Company,  and  his  house-surgeon.  Dr. 
G.  F.  Hamel,  who  have  looked  up  the  statistics,  claim  that  this 
estimate  is  too  small.  This  statement  may  at  first  appear 
startling,  yet  the  experience  of  chief -surgeons  bears  out  this 
(660) 


RAILROADING  AS  A  FACTOR  IN  RECTAL  DISEASE  661 

assertion.  In  talking  this  matter  over  with  Dr.  W.  B.  Outten, 
chief-surgeon  of  the  entire  Missouri  Pacific  Railway  System, 
and  Dr.  N.  J.  Pettijohn,  chief-surgeon  of  the  Kansas  City,  Fort 
Scott  &  Memphis  Railway  Company,  both  agreed  as  to  the  fre- 
quency of  these  diseases  among  railway  men. 

It  is  not  the  desire  of  the  author  to  convey  the  impression 
that  he  believes  75  per  cent,  of  all  men  admitted  to  a  railway 
hospital  for  treatment  have  some  rectal  trouble  requiring  im- 
mediate attention;  on  the  contrary,  he  knows  that  very  few 
enter  the  hospital  to  be  operated  upon  for  rectal  trouble  alone, 
but  to  receive  treatment  for  some  disease,  such  as  typhoid 
fever,  malaria,  pneumonia,  etc.,  or  for  some  accident.  In  fact, 
not  more  than  10  per  cent,  of  said  patients  undergo  treatment 
for  rectal  diseases.  There  are  several  reasons  to  account  for 
this.  In  the  first  place,  ailments  about  the  rectum  are  usually 
considered  chronic,  and  are  sometimes  contracted  before  the 
sufferer  enters  the  railway  service  or  while  employed  by  some 
other  company.  If  such  be  the  case,  it  bars  him  from  treatment 
at  the  company's  expense  in  many  hospitals,  for  only  those 
diseases  contracted  by  the  patients  while  in  the  discharge  of 
their  duties  are  treated  free,  and  some  company  hospitals  treat 
only  those  employees  accidentally  injured.  In  the  second  place, 
such  affections  are  usually  considered  of  minor  importance,  and 
are  rarely  inquired  after  by  the  surgeon  in  charge.  In  the  third 
place,  many  employees  believe  these  diseases  to  be  incurable; 
others  imagine  that  the  treatment  requires  considerable  time, 
is  extremely  painful,  and  frequently  followed  by  complications. 
Hence,  these  sufferers  do  not  make  their  afflictions  known  until 
after  they  have  had  a  profuse  hemorrhage,  suffered  much  acute 
pain,  or  experienced  an  obstruction  of  the  bowel. 

Two  railway  hospitals  in  the  West. — one  in  Kansas  City, 
the  other  in  St.  Louis. —  have  engaged  consultants  on  rectal 
diseases,  and  now  offer  relief  to  this  class  of  sufferers  heretofore 
neglected.  Other  hospitals  are  following  this  example,  and 
their  future  statistics  will,  no  doubt,  show  a  much  larger  per- 
centage of  rectal  diseases  than  in  the  past,  because  employees 
will  soon  learn  how  easily  these  diseases  are  remedied,  and  that 
the  rectal  surgeon  will  not  overlook  them. 

The  author  now  wishes  to  direct  the  reader's  attention  to 
the  ways  in  which  he  beheves  railroading  causes  such  pernicious 
results : — 


662  DISEASES  OF  THE  RECTUM  AND  ANUS 

They  are  as  follows : — 

1.  Irregularities  in  living. 

2.  Erect  position  assumed  by  employees. 

3.  Irregular,  jarring  motion  of  the  train. 

IRREGULARITIES    IN   LIVING 

When  the  habits  and  every-day  life  of  the  average  railway 
employee  are  studied,  it  is  not  such  a  difftcult  matter  to  under- 
stand why  he  is  thus  afflicted.  Certainly  no  other  class  of  men 
are  more  careless  in  their  habits  and  manner  of  living.  This 
is  partly  their  own  fault  and  partly  the  fault  of  their  occupation, 
which  does  not  permit  of  regular  hours  for  sleeping,  eating, 
exercising,  and  attending  to  the  calls  of  Nature.  Consequently, 
when  Nature's  laws  are  violated  for  any  great  length  of  time, 
an  unnatural  condition  of  affairs  is  brought  about  and  disease 
is  produced.  Believing  that  many  of  these  ailments  are  directly 
or  indirectly  due  to  irregularities  in  sleeping,  eating,  respond- 
ing to  the  calls  of  Nature,  and  dissipation,  one  or  all  combined, 
the  author  will  deal  with  these  causes  separately  and  in  detail. 

Irregularities  in  Sleeping.  —  Persons  at  all  familiar  with 
railroad  work  know  that  a  train-crew  does  not  always  have 
regular  hours  for  sleep.  At  one  time  the  train  is  several  hours 
late ;  at  another,  when  their  run  is  completed  and  the  men 
think  they  are  about  to  have  a  few  hours'  rest,  they  are  imme- 
diately sent  out  with  some  other  train  to  take  the  place  of  some 
conductor,  engineer,  fireman,  or  brakeman  who  is  ill  or  for 
some  other  cause.  Again,  many  of  these  men  do  not  have 
regular  day  or  night  runs,  but  one  that  takes  from  thirty-six 
to  forty-eight  hours  (Pullman  conductors  and  porters  and 
crews  of  through  freight-trains).  During  these  hours  they  are 
deprived  of  sleep.  All  know  from  experience  how  the  loss  of 
sleep  disturbs  the  system  in  general.  Finally,  when  trainmen 
have  reached  the  end  of  their  run  and  transacted  any  business 
requiring  immediate  attention,  they  eat  hurriedly  and  then 
many  of  them  go  to  bed  and  sleep  from  eighteen  to  twenty- 
four  hours  or  even  longer,  frequently  remaining  in  a  state  of 
stupor  not  unlike  that  of  a  person  under  the  influence  of  a 
strong  narcotic.  They  do  not  take  time  to  exercise,  talk  to 
their  families,  or  do  anything  except  to  eat  and  sleep,  until  time 
to  go  out  on  their  next  run.  Others  go  to  the  opposite  ex- 
treme, and,  after  taking  a  short  nap,  devote  the  remainder  of 


RAILROADING  AS  A  FACTOR  IN  RECTAL  DISEASE  663 

their  time  to  dissipation  and  "doing  the  town."  All  this  is  con- 
trary to  the  laws  of  Nature.  It  interferes  with  the  circulation, 
keeps  the  nerves  in  a  high  state  of  tension,  and  materially 
checks  physiologic  digestion. 

Irregularities  in  Eating. — Irregularities  in  eating  is  one  of 
the  most  frequent  causes  of  rectal  disease  among  railway  em- 
ployees. Physiology  teaches  that  meals,  to  be  properly  di- 
gested and  assimilated,  should  be  served  at  regular  hours  daily, 
eaten  slowly  and  amidst  pleasant  surroundings,  and  followed 
by  quiet  or  very  moderate  exercise.  Compare  this  physiologic 
process  with  the  manner  in  which  meals  are  served  to  and  par- 
taken of  by  conductors,  engineers,  firemen,  and  brakemen. 
The  longest  stop  for  meals  at  railway  stations  is  from  fifteen 
to  twenty  minutes,  part  of  this  time  being  taken  up  by  the 
respective  duties  of  the  crew.  They  run  into  the  dining-room 
or  to  the  lunch-counter  and  gulp  down  in  ten  minutes  a  quan- 
tity of  food  that  should  require  at  least  one-half  or  three- 
fourths  of  an  hour,  if  properly  eaten;  then  ofif  they  go  at  the 
rate  of  twenty  or  thirty  miles  or  more  an  hour.  What  is  the 
result  ?  Food  which  has  not  been  properly  masticated  or  mixed 
with  saliva  is  forced  into  a  seasick  stomach,  or  one  that  is  being 
continually  rocked  from  side  to  side  by  the  swaying  motion 
of  the  train.  Under  this  constant  excitement  and  turmoil,  an 
insufficient  amount  of  gastric  juice  is  secreted  to  attack  large 
lumps  of  improperly  cooked  meats,  bread,  vegetables,  and 
pastries,  and,  as  a  result,  gastric  digestion  is  materially  inter- 
fered with.  In  time,  however,  the  food,  partly  digested,  is 
dumped  into  the  small  intestine,  where,  for  similar  reasons,  in- 
complete intestinal  digestion  follows.  Finally,  the  undigested 
food  reaches  the  large  intestine,  where  it  may  remain  for  a 
variable  length  of  time,  depending  upon  peristalsis  and  the  dis- 
position and  opportunity  to  empty  the  bowel.  Owing  to  the 
rapid  manner  in  which  the  food  is  taken  and  launched  on  its 
course  through  the  alimentary  canal,  it  would  be  impossible 
for  the  glands  to  secrete  a  sufficient  amount  of  the  digestive 
fluids  properly  to  lubricate  and  to  digest  it,  even  though  the 
other  conditions  were  good.  Consequently,  the  feces  contain 
much  less  fluid  than  they  should  when  the  lower  portion  of  the 
colon  is  reached,  and  are  therefore  prone  to  collect  in  large 
quantities,  which  are  not  easily  moved  by  peristaltic  action. 
The  mucous  membrane  soon  loses  its  sensitiveness,  the  glands 


664  DISEASES  OF  THE  RECTUM  AND  ANUS 

refuse  to  secrete,  and  obstinate  constipation  of  the  worst  form 
is  the  result. 

Irregularities  in  Attending  the  Calls  of  Nature. — It  is  a  rec- 
ognized fact  that  many  railway  men  suffer  from  obstinate  con- 
stipation and  its  many  evil  consequences  as  the  result  of  the 
irregular  manner  in  which  they  respond  to  Nature's  demand 
to  expel  the  excreta.  Frequently  they  defer  an  action  from 
hour  to  hour,  or  from  one  day  to  another,  sometimes  through 
gross  carelessness  on  their  part,  and,  again,  because  their 
duties  will  not  permit  them  to  take  sufficient  time  to  empty  the 
bowel. 

To  enjoy  perfect  health,  a  person  should  have  at  least  one 
free  action  daily.  Physiology  teaches  that  the  feces  collect  in 
the  lower  portion  of  the  sigmoid  and  the  rectum  and  remain 
there  until  shortly  before  stool,  when  peristalsis  begins  and  they 
are  moved  downward  into  the  rectum.  Then  the  desire  to  go 
to  stool  is  felt.  If  this  warning  of  Nature  of  the  approach  of 
the  feces  is  appreciated  and  the  contents  of  the  rectum  is 
promptly  expelled,  all  is  well.  On  the  other  hand,  when  this 
hint  is  ignored,  reverse  peristalsis  may  return  the  feces  above 
the  "valves"  and  into  the  sigmoid,  where  they  remain  until 
again  propelled  into  the  rectum,  reproducing  the  sensation  to 
stool.  Now  if  this,  like  previous  sensations,  is  ignored,  event- 
ually because  of  the  irritation  induced  by  the  fecal  mass,  the 
glands  refuse  to  secrete,  the  mucous  membrane  loses  its  sensi- 
tiveness, the  muscular  coat  its  tonicity,  the  sphincter-muscle 
sometimes  becomes  hypertrophied,  and  large  quantities  of  fecal 
matter  may  accumulate  in  the  sigmoid  and  the  rectum  without 
causing  the  least  desire  to  go  to  stool.  Many  persons  do  not 
have  more  than  one  action  a  week,  and  not  a  few  one  every 
two  weeks.  In  fact,  there  are  very  few,  if  any,  railway  men 
who  do  not  sufifer  to  a  greater  or  less  extent  from  constipation. 

Dissipation. — -It  is  a  deplorable  fact  that  a  great  many  rail- 
way employees,  in  addition  to  their  irregular  manner  of  living, 
are  given  to  dissipation  and  drinking  large  quantities  of  alco-' 
holic  stimulants,  which  unquestionably  predispose  them  to  rec- 
tal disease  on  account  of  the  dilated  and  weakened  condition 
of  the  blood-vessels. 

Taken  altogether,  the  irregularities  in  the  life  of  those  who 
follow  railroading  tend  to  produce  a  sluggish  condition  of  the 
circulation,  of  peristaltic  action,  and  of  the  secretory  glands 


RAILROADING  AS  A  FACTOR  IN  RECTAL  DISEASE  665 

and  organs,  ending  in  constipation.  These  conditions  result  not 
only  in  local,  but  also  in  general,  systemic  disturbances,  and  are 
invariably  aggravated  by  constipation,  which  is  unquestionably 
the  most  frequent  of  all  known  causes  of  rectal  diseases.  Any 
one  of  the  following  diseases  of  the  rectum  and  the  anus  may 
be  caused  by  it.  Most  of  them  are  mentioned  in  the  chapter 
on  constipation,  but  it  is  deemed  best  to  review  them  since  they 
bear  directly  upon  the  topic  now  under  discussion. 

RESULTS   OF   CONSTIPATION 

Hypertrophied  Sphincter. — When  defecation  has  been  de- 
ferred for  several  days  the  feces  accumulate,  the  watery  portion 
is  absorbed,  and  they  become  dry,  hard,  nodular,  and  act  as  an 
irritant;  the  sphincter-muscle  is  excited  to  frequent  contrac- 
tion, and  it  becomes  strong  and  hypertrophied. 

Anal  Fissure. — On  account  of  the  hardened  condition  of 
the  feces,  they  are  very  difficult  to  expel,  oftentimes  making 
at  the  muco-cutaneous  junction  a  rent  which  in  time  becomes 
an  irritable  fissure. 

Ulceration.  —  Ulceration  of  the  rectum  and  sigmoid  is  a 
frequent  symptom  of  persistent  constipation,  because  of  the 
pressure  induced  on  the  nutrient  blood-vessels  by  the  fecal 
mass,  causing  necrosis  of  the  tissues. 

Hemorrhoids. — Constipation  is  productive  of  hemorrhoids 
in  several  ways:  (a)  because  of  obstruction  to  the  return- 
flow  of  venous  blood ;  (b)  because  of  venous  engorgement  of 
the  hemorrhoidal  veins  during  the  violent  and  prolonged  strain- 
ing at  every  stool;  (c)  because  of  the  general  laxity  of  the 
tissues  in  those  suffering  from  constipation  and  fecal  toxemia. 

Prolapse. — A  prolapse  of  the  mucous  membrane  may  be 
caused  by  a  fecal  mass  pushing  it  down  during  defecation; 
again,  it  may  be  the  result  of  a  paresis  of  the  bowel  caused  by 
pressure  of  the  mass  upon  the  nerves. 

Proctitis  and  Periproctitis. — An  inflammation  of  the  rectum 
and  the  surrounding  tissue,  which  may  or  may  not  terminate 
in  abscess  and  fistula,  is  frequently  caused  by  constipation,  as 
a  result  of  injury  to  the  very  sensitive  mucous  membrane  by 
the  hardened  feces,  and,  further,  from  the  fact  that  the  feces, 
when  long  retained,  undergo  decomposition  and  expose  any 
unsound  portion  of  the  membrane  to  the  many  septic  organ- 
isms contained  within  the  rectum. 


6G6  DISEASES  OF  THE  RECTUM  AND  ANUS 

Neuralgia.  —  The  fecal  mass  within  the  rectum  and  sig- 
moid sometimes  presses  upon  the  neighboring  nerves,  causing 
reflex  pains  in  the  region  of  the  sacrum  and  coccyx.  Such 
pains  are  usually  diagnosticated  as  neuralgia  of  the  rectum. 

In  addition  to  causing  the  diseases  just  enumerated,  con- 
stipation may  aggravate  any  other  disease  of  the  rectum  or 
colon. 

Having  endeavored  to  demonstrate  how  constipation  is  very 
often  produced  in  railroad  employees  by  irregularities  in  living 
and  that  it  plays  a  very  important  part  in  the  etiology  of  rectal 
diseases,  the  reader's  attention  must  now  be  called  to  other  causes 
which  are  of  equal  importance  from  an  etiologic  stand-point  and 
about  which  nothing  has  heretofore  been  written. 

ERECT  POSITION 

Trainmen,  as  a  rule,  are  required  to  spend  the  major  por- 
tion of  their  time  while  on  duty  in  the  erect  or  semi-erect  posi- 
tion, which  plays  an  important  part  in  causing  rectal  diseases. 
It  does  so  because  of  gravity  and  the  absence  of  valves  in  the 
rectal  veins,  together  with  the  shaking  motion  of  the  train, 
which  tends  to  produce  congestion  and  a  varicose  condition  of 
the  hemorrhoidal  plexus.  That  able  teacher  and  most  excel- 
lent surgeon.  Van  Buren,  once  said,  in  discussing  the  etiology 
of  hemorrhoids,  that  the  erect  posture  assumed  by  man  un- 
doubtedly played  an  important  part  in  causing  that  disease,  and 
cited  the  fact  that  quadrupeds  never  suffer  from  a  similar  con- 
dition. All  surgeons  must  have  noticed  the  frequency  of  vari- 
cose veins  of  the  lower  extremities  in  clerks  and  others  whose 
duties  compel  them  to  be  upon  their  feet  most  of  the  time.  The 
same  can  be  said  of  railroad  employees,  in  whom  there  fre- 
quently is  a  dilatation,  not  only  of  veins  of  the  lower  extrem- 
ities, but  also  of  the  large  veins  about  the  rectum,  sooner  or 
later  ending  in  hemorrhoidal  disease,  ulceration,  etc. 

IRREGULAR,   JARRING   MOTION 

The  irregular,  jarring  motion  of  the  train  well  deserves  a 
place  as  an  etiologic  factor  in  these  diseases  among  railway 
employees.  Unquestionably  it  tends  to  produce  a  congestion 
of  the  rectal  veins  similar  to  that  seen  in  the  lower  extrem- 
ities. It  has  been  often  observed  by  travelers  that,  after 
sitting  for  some  time  upright  or  semiprone  in  a  chair-car,  the 


RAILROADING  AS  A  FACTOR  IN  RECTAL  DISEASE 


667 


feet  become  swollen,  and  if  the  shoes  are  removed  for  any 
length  of  time,  it  is  a  difficult  matter  to  put  them  on  again. 
Now,  if  the  position  and  jarring  motion  of  the  train  would  pro- 
duce such  a  congestion  of  the  veins  of  the  lower  extremities  in 
so  short  a  time,  it  is  easy  to  understand  how  a  permanent  dila- 
tation of  the  venous  plexuses  about  the  rectum  and  anus  (espe- 
cially since  these  veins  have  no  valves)  might  occur  in  those 
whose  duties  compel  them  to  spend  the  greatest  part  of  their 
time  on  the  train.  This  condition,  in  conjunction  with  the  con- 
stipation induced  by  the  irregularities  of  their  manner  of  living, 
unquestionably  predisposes  them  to  the  numerous  diseases 
found  in  the  ano-rectal  region.  For  similar  reasons,  commer- 
cial travelers  are  frequently  afflicted  with  rectal  diseases,  and 
also  factory  employees  who  are  required  to  be  upon  their  feet 
on  floors  that  are  kept  in  constant  motion  as  a  result  of  the 
working  of  ponderous  machinery. 

To  show  the  proportion  of  rectal  to  other  diseases  among 
railway  employees,  and  also  the  proportion  of  the  various 
rectal  diseases  to  each  other,  the  author  appends  the  follo^ving 


Table  XXVIL 


Author's  Analysis  of  One  Hundeed  and  Seventy 
Thousand  Railway  Cases 


[Treated  in  the  hospitals  o 

E  the  Missouri  Pacific 

Railway  System  from  1884  to  1894, 

showing 

the 

proportion  of  rectal  diseases.] 

4J 

u 

d 
o 

CO 

-a 
'3 

a 

d 

-o  . 

j3  cc 

Hospitals. 

i 

03 

A 

m 

c 
o 
O 

o 

a 

3 
to  ' 

to 

3 

ft 

a 

o 
u 

1   ■ 

a 

:ll 

to 

o 

B 
•< 

d 

o 
>. 
■a 
a 
o 
O 

go 

u 

o 

C 

Total     N 

of  Rectal 

Receiv 

Total  Nu 

of  All  C 

Receiv 

, 

1886 

Fort  Wortt    .  ] 

to 
18S9 

200 

67 

3 

14 

1 

12 

297 

7882 

Marshal    .... 

1886 
1886 

177 

40 

5 

5 

3 

3 

2 

1 

236 

4068 

Bedalla  .   .  .  .  | 

to 
1888 
1886 

1294 

296 

4 

4 

2 

1 

26 

3 

1 

1631 

74&5 

Palestine  •  •  •  ^ 

to 

153 

95 

9 

35 

9 

2     20 

2 

1 

1 

327 

73'J7 

( 

1889 

c 

I8S8 

Kansas  City  .  < 

to 
1894 

1580   658 

21 

72 

8 

2 

59 

13 

3 

2414 

4181 

All  hospitals  .   . 

1885 
1885 

924 1  125 

11 

9 

2 

7 

18 

8 

11 

1115 

20629 

St.  Louis  .   .  .  < 

to 

2745  1111 

239 

no 

42 

24 

206 

149 

'^S 

7 

2 

^ 

4666 

nS928 

i 

1894 

7073  2392 

295 

249 

61 

40 

341 

157 

59 

Totals    .... 

1 

4 

7 

10686 

170570 

Total  number  of  cases  treated  in  hospitals. 

Total  number  of  cases  of  rectal  diseases... 

Percentage  of  rectal  diseases 


.170,570 

.  1U,6S6 

6.4 


668  DISEASES  OF  THE  RECTUM  AND  ANUS 

tables  of  cases  which  represent  no  slight  amount  of  labor  on 
his  part.  In  this  connection  sincere  thanks  are  due  to  Dr.  VV. 
B.  Outten,  of  St.  Louis,  for  kindly  furnishing  his  statistics. 

A  close  analysis  of  the  above  table  shows  some  interesting 
facts  regarding  the  comparative  frequency  of  various  rectal  dis- 
eases. These  figures  differ  materially  from  those  given  by  Al- 
lingham,  Cooper  and  Edwards,  and  others  who  have  attempted 
to  group  these  diseases.  Excluding  those  cases  diagnosticated 
as  "enteritis"  and  "enteralgia,"  which  properly  do  not  belong 
in  a  work  of  this  kind,  there  still  remain  10,188  cases  of  rectal 
and  anal  diseases.  Nearly  every  disease  found  about  the  rec- 
tum and  anus  is  represented.  In  point  of  frequency  constipa- 
tion heads  the  list;  more  than  two-thirds  of  the  entire  number 
— 7073 — entered  the  hospital  to  obtain  relief  from  this  condi- 
tion. Next  comes  hemorrhoids,  2392  cases,  comprising  almost 
one-fourth  of  the  entire  number;  then  ulceration,  295  cases; 
fistula,  249  cases ;  while  other  diseases  occurred  much  less  fre- 
quently. Here  the  usual  order  of  things  is  reversed,  for  in 
Allingham's  analysis  of  4000  cases  of  rectal  disease  treated  at 
St.  Mark's  Hospital,  London,  there  were  one-third  more  fistulas 
than  hemorrhoids.  It  must  be  remembered,  however,  that 
St.  Mark's  has  a  great  reputation  for  the  cure  of  fistula,  and, 
furthermore,  that  this  disease  is  encountered  much  more  fre- 
quently in  charitable  institutions  than  in  private  hospitals. 
Again,  railway  men  are  more  frequently  afflicted  with  hemor- 
rhoids than  fistula,  because  of  the  dilated  condition  of  the  rectal 
veins  induced  by  irregular  habits,  the  erect  position,  and  the 
jarring  motion  of  the  train.  In  fact,  in  his  own  private  prac- 
tice, the  author  has  more  frequently  been  called  upon  to  treat 
hemorrhoids  and  ulceration  than  fistula.  Other  surgeons  in 
this  country  have  had  a  similar  experience.  The  second  table 
gives  a  synopsis  of  the  author's  work  in  rectal  and  anal  surgery 
for  one  year — 1893-1894 — at  the  Kansas  City,  Fort  Scott  & 
Memphis  Railroad  Hospital,  of  which  Dr.  N.  J.  Pettijohn  is 
chief-surgeon.  In  round  numbers,  800  patients  were  treated 
during  this  time.  Of  this  number,  30  entered  the  hospital  to  be 
treated  for  rectal  disease.  Many  other  patients  had  rectal  dis- 
ease, but  considered  it  of  secondary  importance  to  the  disease 
or  accident  which  was  the  immediate  cause  of  their  entering  the 
hospital. 


RAILROADING  AS  A  FACTOR  IN  RECTAL  DISEASE 


6G9 


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gi^O  DISEASES  OF  THE  RECTUM  AND  ANUS 

This  table  is  appended  for  the  reason  that  it  gives  in  brief 
the  percentage  of  rectal  to  other  diseases ;  the  age,  diagnosis, 
complications;  the  treatment  or  operation,  the  length  of  time 
under  treatment  of  each  patient,  and  also  the  very  large  per- 
centage of  these  sufferers  who  can  easily  and  speedily  be  cured 
v^hen  given  the  attention  they  should  receive  in  every  railv^ay 
hospital. 

In  conclusion,  the  reader's  attention  is  called  to  other 
fruitful  sources  of  rectal  disease  among  railway  men,  viz. :  the 
use  of  filthy  cotton-waste,  rags,  and  harsh  and  printed  paper 
for  toilet  purposes ;  also  the  frequent  use  of  dirty  and  improp- 
erly-constructed privies.  These  causes  are  frequently  respon- 
sible for  fissures,  pruritus  ani,  proctitis,  and  infectious  diseases 
of  the  rectum  and  anus. 


CHAPTER  XLl 

LOCAL  ANESTHESIA    IN  THE    TREATMENT    OF    DISEASES 
OF    THE    SIGIVIOID,    RECTUM,  AND    ANUS 

The  author  has  employed  local  anesthesia  extensively  in 
recent  years  in  the  treatment,  both  operative  and  palliative,  of 
affections  of  the  sigmoid,  rectum,  and  anus,  and  the  results  ob- 
tained indicate  that  it  has  a  much  wider  field  of  usefulness  and 
possesses  greater  advantages  than  have  been  assigned  to  it  here- 
tofore by  general  surgeons  or  rectal  specialists.     In  former  edi- 
tions of  this  work  local  anesthetics  were  not  given  so  much  con- 
sideration as  the  author's  experience  has  shown  them  to  deserve, 
and  hence  a  chapter  is  set  apart  in  this,  the  third  edition,  for  a 
more  complete  discussion.     In  writing  this  chapter,  however,  the 
author  does  not  wish  to  convey  the  idea  that  he  condemns  general 
anesthetics.     The  administration  of  a  general  anesthetic  is  im- 
perative for  all  operative  procedures  in  the  upper  rectum,  extirpa- 
tion or  resection  of  the  bowel,  excision  of  the  coccyx,  and  all 
extensive  operations  such  as  are  required  to  remove  large  tumors 
or  to  relieve  complete  extensive  prolapsus  recti,  complex,  horse- 
shoe, recto-vesical,  recto-urethral  and  most  recto-vaginal  fistulse, 
very  extensive  abscesses,  necrosis  of  the  coccyx  and  sacrum,  and 
strictures  and  congenital  malformations  above  the  internal  sphinc- 
ter muscle.    General  anesthesia  is  necessary  also  in  operations  for 
fistute,  hemorrhoids,  fissure,  abscess,  etc.,  complicated  by  other 
more  serious  rectal  disease,  and  when  the  local  anesthesia  does 
not  permit  the  diseased  tissues  to  be  sufficiently  exposed  for  thor- 
ough operation.    The  above-named  more  or  less  grave  affections, 
however,  constitute  but  a  small  proportion  of  the  total  number  of 
cases  coming  under  the  proctologist's  care  and  occur  most  fre- 
quently in  dispensary  and  hospital  practice,  while  the  better  class 
of  patients  are  usually  afflicted  with  the  more  common  and  simple 
diseases  of  the  ano-rectal  region. 

No  matter  how  trivial  the  condition,  however,  it  has  been 
the  custom  of  surgeons  generally  to  require  these  patients  to  post- 
pone all  business  and  social  duties,  to  enter  the  hospital  and  sub- 
mit to  general  anesthesia,  when  in  fact  they  could  easily  have  been 

(671; 


672  DISEASES  OF  THE  RECTUM  AND  ANUS 

operated  upon  in  the  office  or  at  home  under  local  anesthesia  with 
little  or  no  delay  from  their  odinary  duties,  and  without  the 
danger  and  annoyances  which  attend  general  anesthetization. 
Formerly  the  author  also  followed  this  custom,  but  in  recent  years 
he  has  succeeded  in  reducing  annually  the  number  of  his  hospital 
patients  and  now  operates  upon  a  large  proportion  of  his  cases 
under  local  anesthesia  in  the  office,  dispensary  or  patient's  home. 

Local  Anesthetics. — The  local  anesthetics  which  are  used 
more  or  less  extensively  at  present  are:  the  ether  spray,  ethyl 
chloride,  liquid  air,  electricity,  eucaine,  cocaine,  and  distension 
of  the  tissues  by  means  of  injections  of  sterile  water. 

Freezing  the  parts  by  the  ether  spray,  ethyl  chloride  or 
liquid  air  has  but  a  limited  field  in  ano-rectal  operations,  being 
practicable  only  in  affections  involving  the  skin  about  the  anus. 
The  chief  objections  to  this  class  of  local  anesthetics  are  the 
severity  of  the  initial  and  the  post-operative  pain,  the  danger  of 
extensive  sloughing  following  the  freezing  process  and  the  con- 
sequent delay  in  healing. 

Cataphoresis  (electricity)  as  an  aid  in  producing  local 
anesthesia  was  suggested  by  Wagner  in  1886  and  the  careful 
experiments  of  Frederick  Peterson  added  to  the  knowledge  of 
this  subject.  In  1891,  W.  J.  Morton,  a  son  of  the  discoverer  of 
ether  anesthesia,  suggested  the  use  of  a  solution  of  cocaine  hydro- 
chlorate  in  producing  local  anesthesia  by  cataphoresis.  Later  he 
improved  this  method  by  adding  guaiacol,  producing  guaiacolate 
of  cocaine  and  by  means  of  this  agent  he  claims  that  perfect  local 
anesthesia  can  be  produced  with  less  current  (2  to  4  milliamperes) 
and  shorter  time  (2  to  4  minutes)  than  by  former  methods.  He 
uses  five  grains  (0.32  grams)  of  cocaine  hydrochlorate  and  one 
drachm  (4  grams)  of  guaiacol  and  his  electrodes  are  of  block 
tin,  perforated  and  covered  with  blotting  paper,  thus  bringing 
the  solution  and  electrode  into  close  contact  with  the  skin.  After 
the  application  the  skin  is  wiped  with  alcohol  to  remove  the  traces 
of  guaiacol  and  cocaine. 

Cocaine  and  eucaine  in  solution,  alone,  or  in  combination 
with  other  drugs,  have  been  used  widely  for  many  years  to  pro- 
duce local  anesthesia,  but  the  author  believes  that  they  have  not 
been  employed  in  ano-rectal  operations  as  extensively  as  they  de- 
serve. The  popular  favor  bestowed  upon  these  drugs  is  due  in 
a  large  measure  to  the  contributions  to  the  literature  of  this  sub- 
ject by  Corning,  Schleich,  Oberst,  Reclus,  Demont,  and  recently 


LOCAL  ANESTHESIA  673 

Bodine  and  others.  Schleich,  through  his  publications  in  1891 
and  1898  giving  his  experiments  and  his  infiltration  method,  has 
done  more  than  any  other  writer  to  arouse  interest  in  cocaine 
anesthesia.  He,  however,  did  not  employ  cocaine  alone,  but 
combined  it  with  morphia,  his  solutions  for  ano-rectal  operations 
containing  cocaine  1  in  1000,  and  morphia  1  in  5000  parts,  and 
when  this  was  not  sufficient,  he  doubled  the  amount  of  cocaine; 
he  reports  most  satisfactory  results  from  the  use  of  these  solu- 
tions in  this  class  of  work. 

The  author  has  experimented  extensively  during  several 
years  past  with  eucaine  and  cocaine,  including  Schleich's, 
Oberst's,  and  other  combinations,  in  order  to  ascertain  their  value 
in  operations  about  the  rectum  and  anus,  and  has  attained  very 
gratifying  results.  His  experiments  have  demonstrated  beyond 
doubt  that  very  many  of  these  operations  for  which  general 
anesthesia  is  now  administered,  can  be  successfully  and  easily 
performed  under  either  cocaine  or  eucaine  anesthesia  with  no 
pain  except  that  due  to  the  introduction  of  the  needle.  In  the 
early  experiments  solutions  varying  in  strength  from  4  to  6  per 
cent,  were  employed,  but  owing  to  the  frequency  with  which  toxic 
symptoms  followed  their  injection  either  into  the  rectum  or  into 
the  surrounding  tissues,  these  strong  solutions  were  discarded 
and  the  strength  reduced  from  time  to  time,  until  those  now  used 
usually  contain  ^/^  of  1  per  cent.,  and  never  more  than  1  per 
cent,  of  the  drug.  These  solutions  should  be  freshly  prepared, 
as  they  soon  deteriorate.  The  use  of  normal  saline  solution  in 
their  preparation  is  said  to  enhance  their  effectiveness  for  this 
class  of  operations,  but  distilled  water  answers  all  purposes.  The 
author  has  not  found  it  advantageous  to  add  morphia  or  other 
drugs  to  increase  the  anesthetic  effect  or  extract  of  suprarenal 
gland  or  similar  agents  for  the  purpose  of  controlling  hemor- 
rhage ;  the  latter  may  prevent  bleeding  during  the  operation,  but 
following  it  dilatation  of  the  vessels  and  increased  hemorrhage 
may  occur. 

The  technic  of  injecting  cocaine  and  eucaine  solutions  into 
the  tissue  to  produce  anesthesia  will  not  be  described  here,  as  it  is 
very  similar  to  that  of  injecting  sterile  water,  which  is  discussed 
fully  later  in  this  chapter. 

While  experimenting  with  eucaine  and  cocaine  the  author 
found  that  the  weaker  solutions  properly  injected  were  equally 
as  effective  as  the  stronger  ones.     It  was  further  observed  that 


674  DISEASES  OF  THE  RECTUM  AND  ANUS 

neither  produced  satisfactory  anesthesia  when  the  tissues  could 
not  be  distended,  because  of  the  escape  of  the  fluid  through  an 
opening  such  as  exists  in  ulceration  or  fissure,  or  in  fistula  where 
the  needle  was  inserted  so  deeply  that  it  entered  the  sinus.  Upon 
observing  this  latter  fact,  it  occurred  to  the  writer  that  the  anes- 
thetic effect  was  not  due  entirely  to  the  action  of  the  drug,  but 
to  the  pressure  exerted  upon  the  nerves  by  the  injected  fluid,  and 
to  determine  whether  this  were  true  experiments  were  begun  in 
September,  1901,  with  sterile  water,  saline  solutions,  compressed 
air,  and  other  media  which  could  be  used  to  distend  the  tissues. 
Results  proved  that  local  anesthesia  can  be  produced  by  properly 
distending  the  tissues,  and  that  the  distension  is  most  satisfac- 
torily accomplished  by  injections  of  sterile  water  or  saline  solu- 
tion, the  latter  apparently  possessing  no  advantages  over  the 
former.  The  temperature  plays  no  part  in  producing  the  anes- 
thesia, but  it  is  more  agreeable  to  the  patient  if  the  water  is  about 
the  temperature  of  the  body  when  injected. 

The  author  uses  a  syringe  which  holds  about  an  ounce  (30 
cubic  centimeters)  and  which  is  fitted  with  the  Gant  curved 
extension  piece  (Fig.  154),  so  that  the  syringe  barrel  will  not 
obstruct  the  view  when  the  needle  is  inserted. 

Sufficient  water  must  be  injected  to  distend  the  tissues  until 
they  become  anemic  and  glassy  white  in  appearance  before  satis- 
factory anesthesia  is  induced.  The  amount  required  varies  from 
a  few  drops  to  half  an  ounce  (15  cubic  centimeters)  or  more, 
depending  upon  the  resistance  of  the  tissues  and  the  extent  of  the 
operation  to  be  performed. 

The  technic  of  injecting  sterile  water  to  produce  anesthesia 
is  simple.  A  linear  incision  through  the  integument  alone  re- 
quires that  the  water  be  injected  between  the  layers  of  the  skin 
only  along  the  line  to  be  incised.  At  the  point  where  the  needle 
is  to  be  introduced  the  skin  is  caught  up  between  the  thumb  and 
the  forefinger  and  compressed  in  order  to  deaden  sensation,  or 
this  may  be  accomplished  by  eucaine  cataphoresis  or  carbolic  acid ; 
the  needle  is  now  introduced  and  a  small  quantity  of  the  water  is 
injected;  it  is  then  inserted  slowly  further  and  further,  deposit- 
ing the  water  until  an  elongated  whitish  swelling  is  produced. 

If  the  incision  is  to  extend  deeper  into  the  subcutaneous  tis- 
sues, the  latter  are  also  distended  by  plunging  the  needle  through 
the  already  anesthetized  skin  and  depositing  the  water  beneath 
it  along  the  same  line. 


LOCAL  ANESTHESIA  675 

When  a  linear  incision  is  to  be  made  through  the  mucosa, 
submucosa,  and  deeper  tissues  above  the  sphincter  muscle,  as  for 
complete  internal  fistula,  the  removal  of  tumors,  etc.,  the  water 
is  injected  directly  into  these  structures  until  they  are  distended 
sufficiently  to  produce  the  desired  degree  of  anesthesia. 

In  operating  upon  affections  involving  the  anus,  such  as 
fissure,  fistulas,  stricture,  etc.,  where  it  is  desirable  to  divide  the 
sphincter  muscle,  the  injections  of  water  are  first  made  into  the 
skin  and  subcutaneous  structures,  beginning  half  an  inch  (1.25 
centimeters)  or  more  from  the  anal  margin.  The  needle  is  then 
pushed  forward  distending  the  external  and,  if  necessary,  the 
internal  sphincter  muscle,  the  mucosa  and  deeper  tissues.  ° 

Anesthetization  suitable  for  any  of  the  popular  operations 
for  either  variety  of  internal  hemorrhoids  can  be  quickly  pro- 
duced by  injecting  the  water  directly  into  the  center  of  the  tumors. 
In  thrombotic  hemorrhoids,  it  is  necessary  to  distend  only  the 
skin  overlying  the  clot  to  be  evacuated.  External  cutaneous 
hemorrhoids,  however,  require  that  both  the  skin  and  the  tumor 
be  distended. 

The  permanent  cure  of  pile  tumors  can  be  accomplished  by 
this  method,  as  by  means  of  eucaine  or  cocaine,  so  easily  and 
quickly  and  with  so  little  pain  and  delay  from  business  that  the 
author  in  his  private  practice  has  entirely  discarded  the  injection 
method,  which  is  so  uncertain  and  attended  by  so  many  dangers. 

For  the  removal  of  polyps  the  water  is  injected  into  the 
pedicle  or  into  the  mucosa  and  deeper  structures  at  its  attach- 
ment, depending  upon  whether  the  excision,  clamp  and  cautery, 
or  ligature  operation  is  to  be  performed. 

Simple  prolapsus  ani  may  be  successfully  operated  upon  by 
removing,  by  ligature  or  otherwise,  larger  or  smaller  areas  or 
segments  of  the  mucosa  which  have  been  previously  distended 
with  the  sterile  water.  Occasionally  in  more  extensive  cases, 
distension  and  excision  of  sections  of  both  the  mucosa  and  deeper 
structures,  including  the  musculature,  may  be  practiced,  but  in 
very  extensive  or  complicated  cases  general  anesthesia  is  prefer- 
able. For  operations  where  eucaine  or  cocaine  is  employed,  these 
solutions  are  injected  exactly  in  the  same  manner  as  has  been 
recommended  for  the  injection  of  the  sterile  water. 

The  injection  of  sufficient  water  into  internal  hemorrhoids 
or  into  or  beneath  the  mucosa,  may  cause  temporary  discomfort 
due  to  the  stretching  of  the  tissues.    But  when  the  injections  are 


676 


DISEASES  OF  THE  KECTUM  AND  ANUS 


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678  DISEASES  OF  THE  RECTU]\I  AisB  ANUS 

made  into  or  beneath  the  skin  this  distension  pain  may  be  quite 
severe  in  some  cases,  but  disappears  as  soon  as  the  pressure  is 
reheved  by  the  escape  of  the  water  during  the  operation.  The 
cutting  itself  is  very  rarely  accompanied  by  any  pain. 

Bleeding  during  operations  under  sterile  water  anesthesia  is 
very  slight  and  frequently  there  is  none  because  of  the  local 
anemia  produced  by  the  pressure;  after  the  operation  bleeding 
seldom  occurs,  apparently  because  the  relaxation  of  the  vessels, 
so  frequently  encountered  after  cocaine  and  similar  drugs,  seldom 
takes  place  following  the  injection  of  sterile  water. 

The  sterile  water  method  can  be  advantageously  employed 
not  only  in  many  uncomplicated  cases  of  ano-rectal  affections,  but 
it  is  also  practicable  and  can  be  safely  used  in  cases  in  which 
general  anesthetization  and  cocaine  and  similar  drugs  are  contra- 
indicated  because  of  the  existence  of  tubercular  or  other  pulmo- 
nary, nephritic,  or  cardiac  affections. 

The  author's  experiments  with  sterile  water  and  with  weak 
solutions  of  cocaine  and  eucaine  have  shown  that  a  great  many 
ano-rectal  operations  can  be  performed  easily  and  painlessly 
under  any  of  these  methods.  In  suitable  cases,  however,  the 
author  prefers  sterile  water  anesthetization  because  of  the  elimi- 
nation of  danger  from  the  toxic  effects  which  may  accompany 
eucaine  and  cocaine,  and  because  there  is  less  bleeding  during 
and  after  the  operation,  and  post-operative  pain  is  less  frequent, 
not  severe,  and  does  not  persist  nearly  so  long.  In  some  cases, 
however,  with  a  weak  solution  of  either  cocaine  or  eucaine,  the 
initial  pain  due  to  the  stretching  of  the  tissues,  especially  the  skin, 
is  less  and  of  shorter  duration. 

The  author  has  demonstrated  that  internal  hemorrhoids 
located  well  above  the  muco-cutaneous  junction,  and  other  affec- 
tions involving  the  mucosa  alone,  can  be  operated  upon  in  some 
cases  without  any  anesthetic,  causing  the  patient  but  little  if  any 
pain. 

The  author  uses  weak  solutions  of  eucaine  and  cocaine  some- 
times, but  in  order  to  give  some  idea  of  the  extent  to  which  he 
has  employed  sterile  water  anesthesia  in  his  private,  hospital,  and 
dispensary  practice,  he  has  prepared  the  preceding  table  which 
wa'J  included  in  a  paper  read  before  the  meeting  of  the  American 
Proctological  Society,  June,  1904.  Since  this  table  was  prepared 
he  has  operated  upon  numerous  other  cases  under  local  anesthesia 
produced  by  this  method  with  highly  satisfactory  results. 


LOCAL  ANESTHESIA  679 

As  shown  by  the  table,  the  sterile  water  method  was  em- 
ployed with  good  results  in  a  large  number  of  radical  operations, 
including  those  for  the  relief  of  the  following  affections :  internal, 
protruding,  and  bleeding  hemorrhoids ;  external,  cutaneous,  and 
thrombotic  hemorrhoids;  complete,  blind,  internal  and  external; 
complete  internal  and  external  fistulse;  prolapsus  ani,  ulceration, 
polypi,  ischio-rectal,  marginal  and  follicular  abscesses ;  anal  stric- 
ture, congenital  malformations  of  the  anus,  sacral  dermoids, 
lipomata,  epithelioma,  perineal  cysts,  foreign  bodies  beneath  the 
skin  and  mucosa,  constipation  and  fecal  impaction  (division  of 
sphincter)  ;  also  in  colostomy,  coeliotomy  for  intestinal  obstruc- 
tion, exploratory  laparotomy,  and  fixation  of  the  sigmoid  colon  to 
the  abdominal  wall  for  the  relief  of  prolapsus  recti  and  invagina- 
tion. 

Before  concluding  this  discussion  of  local  anesthetics  in  the 
treatment  of  ano-rectal  diseases,  the  author  wishes  to  point  out 
their  value  in  the  non-operative  treatment  of  these  affections. 
The  sterile  water  method  is  useful  only  in  operations,  while  co- 
caine and  eucaine  alone,  or  in  combination  with  other  agents, 
have  a  broader  field  of  usefulness,  since  they  are  serviceable  not 
only  in  the  operative,  but  also  in  the  non-operative  treatment. 

The  pain  caused  by  examination  of  sensitive  patients  and 
that  due  to  the  application  of  strong  remedies,  cauterization  by 
the  thermo-cautery  or  chemical  caustics,  or  the  insertion  of  dress- 
ing in  some  cases  can  frequently  be  materially  lessened  or  pre- 
vented by  the  intelligent  use  of  eucaine  or  cocaine.  For  this 
purpose  a  solution  containing  from  3  to  6  per  cent,  of  cocaine  or 
eucaine  is  employed.  In  small  wounds,  ulcers,  or  fissures  about 
the  anal  margin  or  within  the  grasp  of  the  sphincter  muscle,  the 
application  can  be  made  by  means  of  pledgets  of  cotton  or  gauze 
saturated  with  the  solution,  or  the  latter  may  be  dropped  directly 
upon  the  surface  from  a  small  medicine  dropper.  Over  larger 
denuded  areas  involving  the  skin  or  mucosa  or  both,  the  applica- 
tion may  be  quickly  and  easily  made  by  means  of  the  spray ;  but 
owing  to  the  susceptibility  to  cocaine  or  eucaine  poisoning  when 
these  drugs  are  introduced  into  the  bowel,  the  quantity  used  in 
the  rectum  must  be  limited,  and  in  some  instances  it  is  advisable 
to  employ  weaker  solutions. 

Under  careful  supervision  of  the  physician,  suppositories  or 
ointments  containing  these  drugs,  alone  or  in  combination  with 
morphia,  belladonna,  or  other  remedies,  may  be  used  by  the  pa- 


680  DISEASES  OF  THE  RECTUM  AND  ANUS 

tient  to  relieve  the  pain  and  sphincteric  irritability  symptomatic 
of  many  ano-rectal  diseases,  or  following  operation  in  this  region. 
To  diminish  pain  caused  by  a  fissure,  ulcer,  or  other  sensitive 
wound  about  the  ano-rectal  region  where  it  is  not  desirable  to 
use  eucaine  or  cocaine,  the  best  results  are  attained  from  appli- 
cations of  orthoform  or  analgine. 


INDEX 


Abdominal    wall,    method    of    opening    in 

colostomy,   602. 
Abdomino-perineal     excision     of     rectum, 

569. 
Abnormalities.      (See    "Malformations.") 
Abscess,   ano-rectal   (see  "Abscess,  Ischio- 
rectal"),    cold,     227;      follicular,     226; 
gangrenous,      227;       intermural,      226; 
labial,  227;  marginal,  226;  symmetric, 
227. 
ischio-rectal,   association  with  colon  ba- 
cillus, 133;    diagnosis  of,  228;    etiology 
of,   224;    fistula  in  ano  in,  236;    cause 
of  failure  to  heal,   230;    literature  of, 
232;    pathology  of,  224;    post-operative 
treatment  of,   231;     prognosis   of,   229; 
in  rectal  disturbance,  38;    relation  of, 
to  ischio-rectal   fossae,   19;     symptoms 
of,   226;    treatment  of,  229,  231,  varie- 
ties of,   225. 
pelvi-rectal,   225,   226;     diagnosis  of,  229; 
treatment  of,   231. 
Absorption   in   rectum,   13,   32;     physiology 

of,   32. 
Acid,    carbolic,    in    treatment    of    hemor- 
rhoids, 459,  468. 
nitric,  in  treatment  of  prolapse,  392. 
Actinomycosis,    a    cause    of    rectal    ulcer, 

331. 
Adenocarcinoma,   514;     differential  diagno- 
sis from  polyp,   496. 
Adenoma  destruens,  514;    distobiensis,  487; 
infiltrating,  514;    malignant,  515;    rec- 
tal, 484. 
Age,    in   carcinoma,   510;     in   hemorrhoids, 

410;    in  sarcoma,   527. 
Air,  liquid,   in   ano-rectal  operation,   672. 
Alimentation,  rectal,   32. 
Alllngham,   colotomy  clamp,  606;     incision 
in   inferior  protectomy,   551;     grooved 
director,     259;       ointment     applicator, 
337;     pile-crusher,    464;     scissors,    259; 
method  of  forming  spur  in  colostomy, 
608;     on   venereal    stricture,    351. 
"Aloes"    hard-rubber    bougies,    371. 
Ampulla  of  rectum,  8,  10. 
Amputation  for  prolapse,  400,   406. 
Amussat,    operation    for    congenital    mal- 
formations, 84,  85;    operation  of  lum- 
bar colostomy,  87. 
Anal  canal,  the,  8. 
Anatomy  of  rectum,   3,   8. 
Anesthesia,    chloroform,    49;     cocaine,    49; 
ethyl  chloride,  49;    ether,  49;    general, 
49;    local,   49. 
Anesthesia,      local,     in     diseases     of     the 
sigmoid,    rectum    and    anus,    671;     in 
non-operative      treatment,       679;       in 


operation   for   tubercular   fistula,    281; 
produced     by    cataphoresis,     672;      by 
cocaine,   672;     by  compressed  air,   674; 
by   eucaine,    672;     by    saline    solution, 
674;     by    Schleich's    method,    673;     by 
sterile     water,     674;      table     of     cases 
operated     on,     676;      selection    of,     in 
colostomy,   601. 
Angioma  of  rectum,  490. 
Anus,    the,    18;     chancroids   of,    322;     con- 
genital  malformations   of,   73;     divul- 
sion    of,     18;      elephantiasis    of,     494; 
eversion   of,    50;     examination   of,    41; 
fissure     of     (see     "Fissure,     Anal"); 
fistula    of    (see    "Fistula    in    Ano") ; 
hemorrhage       from       (see       "Hemor- 
rhage");    malignant  growths  of,   377; 
prolapse    of    (see    "Prolapse");     pro- 
trusions  from,   34;     appearance  of,   in 
stricture,    361;     ulcer   of    (see    "Ulcer, 
Non-malignant"), 
artificial.     (See  "Colostomy"  and  "Arti- 
ficial Anus.") 
imperforate,    classification   of,    74;     diag- 
nosis of,   79;    prognosis  of,   81,   symp- 
toms of,  78;    treatment  of,  83. 
pruritus    of,    190;      differential    diagnosis 
from    hemorrhoids,    427;     in    anal   fls- 
ure,  301;    in  fistula  in  ano,  244. 
Appendices  epi.ploicte,  3. 
Applications,      local,      in      non-malignant 

ulcer,  336. 
Applicator,    ointment,    Allingham's,  337. 
Arteries  of  rectum,  14;     mesenteric,   feces 

in   embolism  of,   72. 
Artificial    anus,    closure    of,    620,    622,    624; 
definition  of,  619;    in  fecal  impaction, 
114;      in    fecal    incontinence,    292;      in 
fistula,    265,     267;      Gant's    clamp    for 
closure  of,   620;     Gant's  operation   for 
closure   of,    621;     closure  by   ligation, 
622;     in    malignant    growths,    540;     in 
rectal    stricture,    374;     closure    by   re- 
section and  anastomosis,  622;    in  non- 
malignant  ulcer,   338,  343.      (See   "Co- 
lostomy.") 
Astringents  in  hemorrhage,  480;    in  hem- 
orrhoids,  455. 
Atresia  ani.     (See   "Atresia   Recti.") 
recti,   classification  of,   74;     diagnosis  of, 
79;     prognosis    of,    81;     symptoms    of, 
78;    treatment  of,  83. 
Atrophy  of  intestinal  mucosa,  66. 
Auto-infection.         (See       "Auto-intoxica- 
tion.") 
Auto-intoxication,  causes  of,  122,  124;    cir- 
culatory system  in,  125;     diarrhea  in, 
127;      headache     in,     127;      immunity 

(681) 


682 


INDEX 


Auto-intoxication    (concluded). 

against,  123;  literature  on,  139;  nerv- 
ous system  and,  126;  neuralgia  in, 
127;  pathology  of,  120;  in  rectal  dis- 
ease, 38,  129;  respiratory  system  and, 
125;  skin  in,  126;  symptoms  of,  125; 
treatment  of,  136. 

Avenoliths  in  rectum,  636. 

Bacillus,  Brieger's  feces,  129. 
cholera,  in  feces,  60,  71. 
coli   communis,   129;   diseases  associated 
with,  132;   means  of  invasion  of,  132; 
in  respiratory  diseases,  126. 
lactis  aerogenes,  129. 
neapolitanus,  129. 
pyogenes  fcetidus,  129. 
smegma,  in  anal  fistula,  280. 
subtilis,  in  feces,  56. 

tubercle,    examination   of,    68;    in    feces, 
60,    67;    in   anal   fistula,    280;    staining 
of,  67. 
typhoid,  in  feces,  60,  70. 
uro-septicus,  129. 

Bacon's  operation  for  stricture,  376. 

Bacteria,  in  feces,  56;  in  feces  of  cholera, 
71;  pathogenic,   in  feces,   60. 

Bailey's  method  of  preventing  fecal  incon- 
tinence in  colostomy,  611. 

Ball,  on  anal  fissure,  297. 

Bardenheuer's  method  for  Kraske  opera- 
tion, 546. 

Barger's  artificial  defecator  and  irrigator, 
113. 

Bartholinitis  as  cause  of  ano-rectal  ulcer, 
330. 

Bathing,  in  treatment  of  constipation,  101. 

Bean's  operation  for  prolapse,  394. 

Bernays's  method  for  prevention  of  fecal 
incontinence  in  colostomy,  612. 

Bezoars  in  rectum,  636. 

Bile  in  colon^  62;  in  ileum,  62;  concre- 
ments  in  feces,  54. 

Bilirubin-calcium  in  feces,  54. 

Blennorrhea  (see  "Gonorrhea"),  175. 

Blood,  examination  of,  in  malignant 
growths,  532;  in  examination,  51;  in 
feces  in  intestinal  ulcers,  65;  supply 
of  colon,  4;  supply  of  rectum,  14; 
vessels,  hemorrhoidal,  14;  vessels  of 
rectum,  structure  of,  15. 

Blow-pipe  cautery,  443. 

Bodenhamer,  on  congenital  malforma- 
tions, 73;  on  "rectail  valves,"  22;  rec- 
tal explorer,  363. 

Bodies,  foreign,  in  feces,  54. 

Bodine's  method  of  forming  spur  in  co- 
lostomy, 609. 

Body,  the  coccygeal,  152. 

Borelius's  method  of  performing  Kraske 
operation,  549. 

Bougies,      "Aloes"      hard      rubber,      371; 


Wales's  soft  rubber,  372;  in  divulsion 
of  sphincter,  96. 

Bowel,  amount  to  be  removed  in  colos- 
tomy, 603,  604;  Gant's  method  of 
opening  in  colostomy,  606;  method  of 
opening  in  colostomy,  605,  606,  607; 
Paul's  method  of  opening  in  colos- 
tomy, 605;  Robson's  method  of  open- 
ing in  colostomy,  607;  time  of  open- 
ing in  colostomy,   605. 

Boyer,  on  anal  fissure,  296;  operation  of, 
for  anal  fissure,  314. 

Braune,  method  of  preventing  fecal  in- 
continence in  colostomy,  613. 

BuUard,  on  rectal  stricture,  351,  353;  on 
elephantiasis   of  vulva,    495. 

Cachexia  in  rectal  diseases,  38. 

Calculi,  fecal,  639;  pancreatic,  in  rectum, 
638;  prostatic,  in  rectum,  639;  uri- 
nary, in  rectum,  639. 
intestinal,  635,  636,  637;  diagnosis  of, 
641;  Gant's  table  of,  642;  literature 
of,  643;  symptoms  of,  639;  treatment 
of,  641.     (See  "Concretions.") 

Callisen-Amussat  operation  of  lumbar  co- 
lostomy, 87. 

Canal,  the  anal,  8,  10. 

Cancer,  black,  520,  523;  hard,  519.  (See 
"Carcinoma.") 

Carbolic  acid  in  treatment  of  hemor- 
rhoids, 459,  468. 

Carcinoma,   adeno-,   514;   age  in,   510;   an- 
nular   516;  blood-examination  in,  532; 
a   cause   of    diarrhea,    141;    cauteriza- 
tion   in,    538;     classification    of,    505; 
Cohnheim's    theory    in,    506;    Coley's 
toxin   in,   538;   colloid,   520;    colostomy 
for,  539;  columnar  celled,  514;  compli- 
cations   in,    527;    curettage    for,    540 
cylindric  celled,  514,  530;  diagnosis  of, 
529;   divulsion  for,   541;   electricity  in 
537;    etiology    of,    506;    feces    in,    72 
fibro-,    519;    hemorrhage    in,    474;    he^ 
redity  theory  of,  509;  history  of,  502 
literature     of,     577;     melanotic,     520 
metastases    in,    527;    microscopic    ex- 
amination    of,     532;     ossifying,     520 
palliative  treatment  of,  534;  parasitic 
theory    of,     507;     pathology    of,     510 
proctectomy  for  (see  "Proctectomy") 
proctotomy  for,  540;  prognosis  of,  533 
protuberant,    516;     radical    treatment 
of,    146,    541;    Roentgen    ray    in,    537 
scirrhous,    519;    squamous   celled,    511 
530;    surgical    treatment    of,    146,    539 
symptoms  of,  524;  table  of  location  of, 
503;  traumatic  theory  of,  508;  tubular 
516;  urine  examination  in,  532. 
differential  diagnosis  of,   from  fecal  im- 
paction,   111;    from    esthiomene,    342; 
from   hemorrhoids,    426;    from    polyp, 


INDEX 


68c 


Carcinoma,     differential     diagnosis     (con- 
cluded). 
531;  from  prolapse,  3S8;  from  sarcoma, 
532. 
Carrier,  gauze,  Darmack,  267. 
Catarrh,    intestinal,    acute,    character    of 
feces    in,    62;    chronic,    character    of 
feces  in,  63. 
of  rectum.     (See  "Proctitis.") 
Caustics,  injection  of,  in  hemorrhoids,  455. 
Cauterization,  in  anal  fissure,  312;  in  hem- 
orrhage, 480;  in  internal  hemorrhoids, 
463;    in    malignant    growths,    538;    in 
non-malignant     ulcer,     337,     345;     for 
polyp,  498,  499;  for  prolapse,  392,  394, 
404,   405. 
Cautery,     blow-pipe,    443;    irons,     444;     le 

Roy,    404;    improved   Paquelin,   439. 
Cecum,  anatomy  of,  3. 
Celiac  flux,  329. 
Celio-proctectomy,  569, 
Chadwick,   on  "rectal  valves,"  21. 
Chambers,  the  rectal,  10. 
Chancre,  hemorrhage  in,  474;  rectal,  321. 
hard,   symptoms,   179;   treatment,   180. 
soft.     (See  "Chancroids.") 
Chancroids,    ano-rectal,    322;    clinic   mani- 
festations, 178;  etiology  and  pathology 
of,  178;  hemorrhage  in,  474;   as  cause 
of    stricture,    354;    symptoms    of,    178; 
treatment  of,  179. 
Charcot-Leyden  crystals  in  feces,  57. 
Chetwood  operation  for  fecal  incontinence, 

292. 
Childhood,  anal  fissure  in,  304. 
Children,  rectal  ulceration  in,  319. 
Chloroform,   in   colostomy   operation,   601; 

in  examination,  49. 
Chlorosis,  cause  of,  110. 
Cholera,  bacillus  of,  in  feces,  60;  feces  in, 

71. 
Cholesterin  crystals  in  feces,  54. 
Circulation,    condition   of,    in   auto-intoxi- 
cation, 125. 
Cirrhosis,  hepatic,  feces  in,  67. 
Clamp,  AUingham's  colotomy,  606. 
Gant's,    for    closing    artificial    anus,    62; 
operation   for   constipation,    104;    pile, 
442;  prolapse  and  polyp,  438. 
Martin's,  443. 
Smith's    442. 
Clamp-and-cautery   operation    for    hemor- 

rhDids,   436,   470. 
Clamp-forceps,  Barle's,  454. 
Clamping  in  hemorrhage,  480. 
Clap.     (See  "Gonorrhea.") 
Clothing  in  the  treatment  of  constipation, 

101. 
Clover's  crutch,  434. 
Cocaine    in    colostomy    operation,    602;    In 

examination,  49. 
Coccygeal  body,  the,  152;  literature  of,  172. 


Coccygodynia,   153;   diagnosis  of,   155;   eti- 
ology and  pathology  of,  154;  progno- 
sis of,   155;   literature  of,   173;   symp- 
toms of,  154;  treatment  of,  155. 
Coccygogectomy,  156,  157. 
Coccyx,  abnormalities  of,  149;  absence  of, 
151;   dislocation  of,  159;   displacement 
of,    a    cause    of    neuralgia,    626,    633: 
fracture  of,  159;  floating,  151;  injuries 
to,   159. 
malformations    of,    149;    as    a    cause    of 
diarrhea,      142;     symptoms     of,      150; 
treatment   of,    150;    literature   of,    172. 
necrosis  of,  160;  operations  on,  156,  157; 
synopsis   of   cases   of   disease   of,   168, 
169,   170,   171;   syphilis  of,   166;   tuber- 
culosis of,  166;  tumors  of,  161. 
Cohnheim's   theory   for    carcinoma,    506. 
Cold  abscess,  %zl. 

Coley's  toxin.   In  malignant  growths,  538. 
Coli  communis  bacillus,   129;   diseases  as- 
sociated with,  132;  means  of  invasion 
of,  132. 
Colon,   anatomy  of,  3;  bile  in,  62;   blood- 
supply    of,    4;    dilatation   of,    38,    110; 
diverticulse  of,  5;  divisions  of,  3;  ex- 
amination  of,   41;   intussusception   of, 
Into  rectum,  387;  invagination  of,  into 
lower    rectum,     387;     location    of,     5; 
lymphatics   of,    4;    nerves   of,   5;   pro- 
lapse of,  into  lower  rectum,  387;  soli- 
tary   glands    of,    4;    structure    of,    in 
infants,  7. 
sigmoid,    anatomy    of,    6;    boundary    of, 
9;  length  of,  7;  location  of,  7;  phys- 
iology of,  29. 
Colonoscope,  45;  manipulation  of,  17. 
Colopexy  for  prolapse,  398. 
Colo-proctitis,    membranous,    etiology    of, 
216;  evacuations  in,  218;  literature  of, 
222;    pathology    of,    217,    219;    "rectal 
valves"   in,   219;   Byron  Robinson  on, 
218;  symptoms  of,  iii.9;  synonym,  216; 
treatment  of,  216. 
Colo-proctostomy,  573. 
Color  of  skin,   a   symptom  of  rectal   dis- 
turbance, 39. 
Colostomy,   AUingham's  method  of  form- 
ing spur  in,   608;    after-treatment   in, 
600;      anesthetics     in,     601;      Bailey's 
method    of    preventing    fecal    incon- 
tinence in,   611;   Bernays's  method  of 
preventing  fecal  incontinence  in,  612; 
Bodine's  method  of  forming  spur  in, 
609;   amount  of  bowel  to  be  removed 
in,    602,    604;    time   of   opening    bowel 
in,   60t;  Braune's  method  of  prevent- 
ing   incontinence    in,    613;    classifica- 
tion   of,    586;    complications    in,    615; 
Gant's     operation     for,     606;     Gant's 
method    of    preventing    fecal    incon- 
tinence   in,    614;     Gant's    method    of 


684 


INDEX 


Colostomy  (concluded). 

opening  bowel  in,  606;  general  re- 
marks on,  601;  Gersuny's  method  of 
preventing  fecal  incontinence  in,  613; 
history  of,  582;  fecal  incontinence  in, 
prevention  of,  610;  incision  for,  584; 
fecal  incontinence  in,  292;  indications 
for,  584;  Kelsey's  method  of  forming 
spur  in,  608;  literature  of,  617;  in 
malignant  growths,  539;  Mathews's 
method  of  forming  spur  in,  609; 
Maydl's  method  of  forming  spur  in, 
608;  mortality  in,  583;  Paul's  opera- 
tion for,  605;  disposal  of  peritoneum 
in,  602;  prolapse  following,  589,  616; 
Robson's  method  of  opening  bowel 
in,  607;  Schinzinger's  method  of  pre- 
venting fecal  incontinence  in,  611; 
sequels  of,  615;  for  stricture,  374,  378: 
stricture  following,  61o;  in  non-malig- 
nant ulcer,  338,  343;  Weir's  method  of 
forming  spur  in,  608;  Weir's  method 
of  preventing  fecal  incontinence  in, 
618;  Witzel's  method  of  preventing 
fecal  incontinence  in,  612;  Wyeth's 
method  of  preventing  fecal  inconti- 
nence in,  613. 

iliac,  left,  temporary,  596;  left,  perma- 
nent, operation  for,  589;  inguinal,  ad- 
vantage of,  over  lumbar,  587;  advan- 
tage of  lumbar  over,  588;  operation 
for,  87. 

Inguinal,  left,  permanent,  operation  for, 
589;   temporary,   596;   provisional,   596. 

inguinal,  right,  599. 

lumbar,  advantage  over  inguinal,  588; 
advantage  of  inguinal  over,  587;  op- 
eration for,  87. 

lumbar,  left,  599;  right,  600. 

permanent  left  iliac,  operation  for,  589; 
left  inguinal,   operation   for,   589. 

provisional  left  inguinal,  596. 

temporary  left  iliac,  596;  left  inguinal, 
596. 

transverse,  598. 
Colotomy.    (aee   "Colostomy.") 
Columns  of  Morgagni,  13. 
Concretions,  bile,  in  feces,  54;  rectal,  635; 
diagnosis   of,    641;    hairy,    636;    Gant's 
table  of,   642;   literature  of,   643;   mis- 
cellaneous,    639;     symptoms    of,     639; 
treatment    of,    641.      (See    also    "En- 
teroliths.") 
Condylomata  acuminata,  183;  diagnosis  of, 
184;     differential     diagnosis     of,     184; 
hemorrhage   in,    474;    lata,    182;    cause 
of,   321;    literature   of,    188;    symptoms 
of,   183;   syphilitic,   182;   treatment  of, 
184;   varieties  of,    182. 
Congestion,   biliary,   feces  in,  53. 
Constipation  as  cause  of  anal  fissure,  295, 
301;   etiology  of,   35,   90;   feces   in,  53; 


In  hemorrhoids,  412;  Gant's  clamp  op- 
eration for,  104;  a  cause  of  neuralgia, 
625;  Martin's  operation  for,  105;  rela- 
tion of,  to  "rectal  valves,"  24;  results 
of,  665;  a  symptom  of  rectal  disturb- 
ance, 35;  symptoms  of,  92;  treatment 
of,  94;   surgical  treatment  of,  102. 

Contraction,  spasmodic,  of  sphincter,  dif- 
ferential diagnosis  from  anal  fissure, 
305. 

Cooper,  on  cause  of  stricture,  350,  351. 

Coproliths,  rectal,  639. 

Coprostasis.     (See  "Impaction,  Fecal.") 

Cripps's  table  on  stricture,  352. 

Crusher,  pile,  Allingham's,  464;  Pollock's 
hemorrhoidal,  464. 

Crushing  method  in  hemorrhoids,  465. 

Crutch,  Clover's,  434. 

Crypts  of  Lieberktihn  in  rectum,  412. 

Crystals,  Charcot-Leyden,  in  feces,  57;  In 
feces,  56. 

Curetting  for  malignant  growths,  540;  in 
non-malignant  ulcer,  338;  for  rectal 
ulcer,  illustrative  case,  344. 

Cutaneous  affections,  a  cause  of  pruritus 
ani,   191. 

Cystitis   in   recto-vesical   fistula,    245. 

Cystoma,  rectal,  492. 

Cysts,  dermoid,  rectal,  491;  a  cause  of 
fistula  in  ano,  237;  sacro-coccygeal, 
161. 

Darmack's  gauze  carrier,  267. 

Defecation,  action  of  levator  ani  muscle 
in,  17;  action  of  recto-coccygeus  mus- 
cle in,  17;  action  of  transversus  peri- 
nei  muscle  in,  17;  cause  for  desire 
for,  30;  consistency  of,  in  disease,  35; 
frequency  of,  31;  frequency  of,  in  dis- 
ease, 35;  mechanism  of,  30;  physiology 
of,  29,  91. 

Defecator,    Barger's   artificial,    113. 

Dejecta.     (See  "Feces.") 

Dermoid  cyst,   rectal,  491. 

Dermophymata  venerea,  182. 

Diarrhea  in  auto-intoxication,  127;  cause 
of,  35;  character  of  feces  in,  62;  in 
intestinal  ulcers,  65;  in  non-malig- 
nant ulcer,  331;  a  symptom  of  fecal 
impaction,  109;  a  symptom  of  rectal 
disturbance,  35. 
chronic,  cause  of,  140;  condition  of  rec- 
tum in,  142;  diagnosis  of.  144;  para- 
sites in,  60;  symptoms  of.  143;  treat- 
ment of,  144. 
nervous,  character  of  feces  in,  64. 

Diet,  irregular,  a  cause  of  pruritus  ani, 
191;  in  malignant  growths,  534;  in 
rectal  stricture,  366;  in  non-malignant 
ulcers,  336;  in  treatment  of  constipa- 
tion,  100. 

Dilatation   of    anus,    18;    of    colon,    38;    lo 


INDEX 


685 


Dilatation  of  anus   (concluded). 

anal    fistula,    252;    of    rectum,    38;    of 
sigmoid  colon,  38;  of  sphincter,  435. 

Dilator,  anal,  ideal,  368;  Durham's,  369; 
Whitehead's,  370. 

Director,  Allingham's  grooved,  259;  Gant's 
grooved,  258,  261. 

Discharges,  in  anal  fissure,  301;  intestinal, 
in  examination,  52;  in  non-malignant 
ulcer,  333;  in  rectal  disease,  36. 

Distension  of  bowel  in  examination,  51. 

Disease,  local,  as  a  cause  of  pruritus  ani, 
190. 
of  skin,  relation  of,  to  rectum,  37. 
recta!,  hemorrhage  in,  35;  ordinary  seat 
of,  9;  pain  in,  34;  railroading  an 
etiological  factor  in,  660;  constipation 
an  etiological  factor  in,  665;  dissipa- 
tion an  etiological  factor  in,  662;  erect 
position  an  etiological  factor  in,  666; 
irregularities  of  living  an  etiological 
factor  in,  662;  jarring  motion  an  etio- 
logical factor  in,  666;  leucocytosis  in, 
51;  symptoms  of,  34;  tables  on  rail- 
roading as  an  etiological  factor  in, 
667-669. 
venereal,  175;  of  rectal  region,  175; 
literature  of,  188;  caused  by  sodomy 
and  onanism. 

Dissipation  as  cause  of  rectal  disease,  662. 

Diverticulae  of  colon,  5;  photograph  of,  5. 

Divulsion  of  anus,  18;  in  anal  fissure,  313; 
in  anal  fistula,  257;  in  hemorrhoids, 
464;  in  malignant  growths,  541;  of 
sphincter,  96,  313;  for  stricture,  380; 
for  tubercular  fistula,  282;  in  non- 
malignant  ulcer,  338. 

Drainage-tube,   rectal,   477. 

Dupuytren's  operation,  for  prolapse,  395. 

Durham's   dilator,    369. 

Dusting-powders  in  treatment  of  .  ulcer, 
337. 

Dysentery,  a  cause  of  ano-rectal  ulcer, 
327;    feces   in,    69. 

garle's  clamp-forceps,  454;  operation  for 
hemorrhoids,  453. 

Eating,  irregularities  in,  a  cause  of  con- 
stipation, 92. 

Ecraseur,   in  hemorrhoids,  466. 

Eczema  in  anal  fissure,  312. 
marginatum,    a    cause    of    pruritus    ani, 
191. 

Edebohls's  operation  of  vaginal  proctec- 
tomy, 572. 

Edwards,  on  cause  of  stricture,  350,  351. 

Electricity  in  constipation,  95,  99;  in 
malignant  growths,  537. 

Electrolysis  in  anal  fistula,  255;  in  strict- 
ure, 370. 

Elephantiasis,  ano-vulvar,  494;  treatment 
of,  499;    Bullard  on,  495. 


Embolism  of  mesenteric  artery,  feces  in, 
72. 

Enchondroma,   rectal,  492. 

Endarteritis  as  cause  of  stricture,   353. 

Endoscope,  recto-colonic,  46;  Bodenham- 
er's,  59. 

Enemata,  absorption  of,  in  rectum,  32;  in 
constipation,  95,  98;  in  fecal  impac- 
tion, 112;  method  of  procedure,  98;  in 
rectal  examination,  41;  rashes  in,  99. 

Enteritis,  interstitial,  217. 
membranous,   character  of  feces  in,   64. 

Enterocolitis,  membranous,   143. 

Enteroliths,  rectal,  635,  637;  diagnosis  of, 
641;  Gant's  table  of,  642;  literature  of, 
643;  symptoms  of,  639;  treatment  of, 
641.  (See  also  "Concretions"  and 
"Calculi.") 

Epithelioma,  true,  511,  530. 

Epithelium,  in  feces,  53,  62;  of  rectum, 
12;  transitional,  between  skin  and 
rectal  mucosa,   12. 

Erect  position  as  cause  of  rectal  disease, 
666. 

Erysipelas  in  rectal  region,  228;  toxin,  in 
malignant  growths,  538. 

Esthiomene,  diagnosis  of,  342;  etiology  of, 
339;  literature  of,  347;  pathology  of, 
339;  symptoms  of,  341;  treatment  of, 
342. 

Ether  in  examination,  49;  in  colostomy 
operation,  601. 

Ethyl  chloride  in  examination,  49. 

Eucaine  in  colostomy  operation,  601. 

Eversion  of  anus  and  rectum,  method  of, 
50. 

Examination,  anesthesia  in,  48;  aspirating 
needle  in,  47;  blood  in,  51;  bougies 
in,  47;  colonoscope  in,  45;  distension 
in,  51;  exploratory  incision  in,  51;  of 
feces,  52;  in  anal  fissure,  303;  fluctua- 
tion m,  50;  gas-light  in,  43;  head- 
mirror  in,  43;  inspection  in,  51;  in- 
testinal discharges  in,  52;  instruments 
for,  42;  knee-chest  position  in,  47; 
light  in,  43;  method  of,  in  malignant 
growths,  529;  proctoscopic,  in  malig- 
nant growths,  529;  mirror  in,  44;  pal- 
pation in,  50;  percussion  in,  50;  posi- 
tion in,  48;  preparation  for,  41;  probes 
in,  47;  proctoscope  in,  45;  specula  in, 
44;  proctoscopic,  for  stricture,  363; 
succussion  in,  51;  table  for,  42;  urine 
in,  51. 
digital,    direction   of,   9;   method   of,   49; 

in  malignant  growths,  529. 
microscopic,  of  feces,  55. 
vaginal,  50. 

Excision,  abdomino-perineal,  569;  in  anal 
fissure,  256,  315;  in  tubercular  fistula, 
282;  for  hemorrhoids,  448;  by  invagi- 
nation,   570;    Maunsell's    method    of. 


686 


INDEX 


Excision  (concluded). 

571;  in  prolapse,  400,  406;  sacral,  554; 
Steinttial's  method  of,  571;  for  strict- 
ure, 372. 
perineal,  in  malignant  growths,  544,  551. 
(See  also   "Proctectomy.") 

Exercise  in  constipation,  100. 

Explorer,  rectal,  Bodenhamer's,   363. 

Extirpation    of    rectum.      (See    "Proctec- 
tomy.") 

Fecal  calculi,  639.  (See  also  "Entero- 
liths.") 

Fecal  fistula.     (See  "Fistula,  Fecal.") 
impaction.     (See  "Impaction,   Fecal.") 
incontinence.      (See    "Incontinence,    Fe- 
cal.") 

Feces,  appearance  of,  52;  bacillus  of 
cholera  in,  60,  71;  bacillus  of  tuber- 
culosis in,  60;  bacillus  of  typhoid  in, 
60;  bacteria  in,  56,  60,  71;  bile-concre- 
ments  in,  54;  bilirubin-calcium  in, 
54;  in  biliary  congestion,  53;  blood  in, 
65;  in  cancer  of  rectum,  72;  in  acute 
intestinal  catarrh,  62;  in  chronic  in- 
testinal catarrh,  63;  characters  of,  in 
disease,  35,  37,  53,  62,  63,  64,  65;  Char- 
cot-Leyden  crystals  in,  57;  choles- 
terin  in,  54;  in  cirrhosis  of  liver,  67; 
color  of,  in  disease,  53;  in  congestion 
of  portal  system,  72;  consistency  of, 
31,  35,  37,  53;  in  constipation,  53; 
crystals  in,  56,  57;  descent  of,  action 
of  "rectal  valves"  on,  20,  24;  in  dys- 
entery, 69;  in  embolism  of  mesenteric 
artery,  72;  in  enteritis  membranacea, 
64;  epithelium  in,  56,  62;  examination 
of,  52,  55;  in  recto-labial  fistula,  248; 
in  recto-urethral  fistula,  248;  in  recto- 
vaginal fistula,  248;  in  recto-vesical 
fistula,  248;  food-remnants  in,  55; 
foreign  bodies  in,  54;  form  of,  53; 
gall-stones  in,  54,  55;  gonococcus  in, 
61;  hemorrhage  in,  53;  in  hepatic 
cirrhosis,  67;  in  icterus  catarrhalis, 
60;  impaction  of,  30,  108  (see  also 
"Impaction,  Fecal");  in  intussuscep- 
tion, 72;  in  degeneration  of  liver,  67; 
location  of,  10;  in  malignant  growths, 
522,  525;  microscopic  examination  of, 
52,  55;  mucus  in,  53,  61,  64;  in  nerv- 
ous diarrhea,  64;  parasites  in,  59; 
pathogenic  bacteria  in,  60;  in  portal 
congestion,  72;  pus  in,  62,  65;  quan- 
tity of,  53;  reaction  of,  54;  in  rectum, 
72;  action  of  "rectal  valves"  on,  90; 
salts  in,  56;  in  scorbutus,  72;  in  tu- 
berculosis, 67;  in  typ-ioid  fever,  70; 
in  syphilis  of  the  rectum,  72;  in 
ulceration   of  the  intestine,    65. 

Fecoliths,    639.      (See   also    "Enteroliths.") 

Feeding  per  rectum,  32. 


Fibrocarcinoma.  519. 

Fibroma,   488;    differential   diagnosis  from 
sarcoma,   522. 

Fissure,  anal.  Ball  on,  297;  bladder  com- 
plications in,  316;  Boyer  on,  296; 
Boyer's  operation  for,  314;  cauteriza- 
tion in,  312;  in  children,  304;  compli- 
cations in,  307;  constipation  in,  295, 
301,  316;  a  cause  of  constipation,  92; 
a  symptom  of  constipation,  93;  diag- 
nosis of,  303;  diet  in,  308;  discharges 
in,  301;  divulsion  of,  313,  314;  eczema 
in,  312;  etiology  of,  295;  excision  in, 
315;  fiatulence  in,  301;  hemorrhage  in 
301,  474;  hemorrhoids  in,  296,  302,  317 
history  of,  294;  illustrative  cases,  316 
irritation  from,  transferred  to  other 
parts,  15;  literature  of,  317;  melan- 
cholia in,  302;  method  of  examination 
in,  303;  multiple,  304;  nervousness  in, 
302;  operative  treatment  of,  312;  pain 
in,  300,  309;  non-operative  treatment 
of,  307;  pathology  of,  295;  post-opera- 
tive treatment  of,  316;  proctitis  in, 
301;  prognosis  of,  306;  pruritis  in,  301; 
Recamier's  operation  for,  313;  reflex 
disturbance  in,  302;  "sentinel  pile" 
in,  297,  298,  302;  use  of  specula  in,  304; 
stimulation  in,  311;  regulation  of 
stools  in,  308;  symptoms  of,  300; 
syphilis  in,  303,  304;  threadworms  in, 
312;  semilunar  valve  in,  298,  299. 
differential  diagnosis  from  ano-rectal 
fistula,  306;  from  disease  of  neighbor- 
ing organs,  306;  from  hemorrhoids, 
306;  from  rectal  neuralgia,  306;  from 
spasmodic  sphincteric  contraction, 
305;   from  ulcer,   303. 

Fistula,  ano-rectal,  abscess  as  cause  of, 
236;  after-treatment  of,  267;  blind  ex- 
ternal, 239;  blind  internal,  239,  247; 
complete,  238,  247;  complex,  262,  270; 
definition  of,  233;  dermoid  cyst  in, 
237;  diagnosis  of,  245,  306;  dilatation 
of,  252;  direction  of,  246;  division  of, 
256;  electrolysis  of,  255;  etiology  of, 
236;  examination  for,  246;  excision  of, 
256;  external,  260;  external  complete, 
240,  247,  261;  fecal  incontinence  in, 
249,  260,  262;  history  of,  133;  cause  of 
failure  to  heal,  236;  horseshoe,  241, 
247,  261,  271;  incision  in,  258,  260:  in- 
jection in,  252;  illustrative  case,  270; 
incontinence  of  feces  in,  249,  260,  262; 
internal  complete,  240.  261;  instru- 
ments for  operation  on,  254;  ligation 
in,  253;  literature  of,  284;  nature  of, 
245;  location  of  opening  in,  247;  op- 
erative treatment  in,  250;  pain  in, 
244;  non-operative  treatment  of,  250; 
pathology  of.  236;  preparation  of  pa- 
tient for  operation  in,  251;  secondary 


INDEX 


687 


Fistula,  ano-rectal   (concluded). 

to  periproctitis,  236;  in  rectal  dis- 
turbance, 38;  relation  of,  to  ischio- 
rectal fossse,  19;  relation  of  phthisis 
pulmonalis  to,  250,  275;  prognosis  of, 
248;  pruritus  ani  in,  244;  pulmonary 
tuberculosis  in,  250,  275;  pus  in,  244; 
symptoms  of,  243;  treatment  of,  269; 
tubercle  bacilli  in,  279;  varieties  of, 
238. 
fecal,  definition  of,  619;  with  imperforate 
anus,  74,  75;  with  congenital  mal- 
formation, treatment  of,  85,  86;  litera- 
ture of,  624;  methods  of  closing,  623; 
literature  on  closure  of,  619. 
recto-labial,    242;    feces   in,    248;    gas   in, 

248;  treatment  of,  264. 
recto-urethral,    241;    artificial    anus    in, 
267;    diagnosis   of,    248;    feces   in,   248; 
gas   in,    248;    treatment   of,   265;    Tut- 
tle's  operation  for,  266. 
recto-vaginal,  240;  feces  in,  248;  gas  in, 

248;  treatment  of,  263. 
recto-vesical,  241;  artificial  anus  in,  265; 
cystitis  in,  245;  diagnosis  of,  248;  feces 
in,  248;  gas  in,  248;  operation  for,  265; 
treatment  of,  85,  264. 
recto-vulvar,   treatment  of,  264. 
tubercular,  anesthesia  in,  281;  diagnosis 
of,  248;   differential  diagnosis  of,  278; 
division  of,  282;  excision  of,  282;  illus- 
trative   case,     283;     ligation    of,     282; 
literature  of,  284-;  operative  treatment 
of,    281;    pus   in,    244;    smegma   bacilli 
in,    280;    treatment    of,    280;    tubercle 
bacilli  in,  279;  varieties  of,  278. 
urinary,  241. 

Fistulatome,   Mathews's,  255. 

Fixation,  ventral,  for  prolapse,  398. 

Flatulence,  in  anal  fissure,  301;  in  rectal 
disturbance,  38. 

Flexure,  sigmoid,  anatomy  of,  6;  examina- 
tion of,  41. 

Fluctuation  in  examination,  50. 

Fluids,  astringent  and  caustic,  injection 
of,  in  hemorrhoids,  455,  468. 

Flux,  celiac,  329. 

Folds,  rectal,  19. 

Follicles  solitary,   of  intestine,  4. 

Follicular  abscess,  226. 

Food-remnants  in  feces,  55. 

Forceps,  Earle's  clamp,  454;  Gant's  hem- 
orrhoidal and  tissue,  436;  Gant's 
recto-colonic,  498;  Mathews's  pile, 
445;  Thomas's  curved  tissue,  445. 

Foreign  bodies  in  rectum,  illustrative 
case,  650;  literature  of,  652;  symptoms 
of,  648;  treatment  of,  649.  (See  also 
"Enteroliths.") 

Fossse,  ischio-rectal,  19;  relation  of,  to 
abscess  and  fistula,  19. 

Fowler's  operation  for  prolapse,   398,   402. 


Fracture  of  coccyx,  159. 
Furunculosis,  anal,  225. 

Qall-stones  in  feces,  54,  55;  in  rectum,  635. 

Gangrene  in  prolapse,  389. 

Gangrenous  abscess,  227. 

Gant's  clamp  operation  for  closure  of  arti- 
ficial anus,  621;  clamp  for  closing 
artificial  anus,  620;  clamp  operation 
for  constipation,  104;  pile,  polyp,  and 
prolapse  clamp,  438,  442;  coccygogec- 
tomy  operation,  157;  colostomy  opera- 
tion, 606;  angular  grooved  director, 
261;  grooved  director,  258;  table  of 
enteroliths  and  concretions,  642; 
method  of  preventing  fecal  incon- 
tinence in  colostomy,  614;  hemor- 
rhoidal and  tissue  forceps,  436;  recto- 
colonic  forceps,  498;  modification  of 
Kraske  operation,  555;  probes,  258; 
combined  operation  for  prolapse,  400; 
posterior  proctoplasty  for  prolapse, 
395;  table  of  rectal  cases  treated  in 
railway  hospitals,  667,  669;  coccygeal 
scissors,  158;  operating  speculum, 
315;  ointment  syringe,  337;  table  on 
stricture,  352;  operation  of  "valvot- 
omy,"  104;  wire  operation  for  pro- 
lapse, 394. 

Gas,  in  recto-labial  fistula,  248;  in  recto- 
urethral  fistula,  248;  in  recto-vaginal 
fistula,  248;  in  recto-vesical  fistula, 
248. 

Gas-light  in  examination,   43. 

Gauze  carrier,  Darmack's,  267. 

Gersuny's  method  of  preventing  fecal  in- 
continence in  colostomy,  613;  modi- 
fication of  Kraske  operation,   550. 

Gland,  the  coccygeal  (see  "Coccygeal 
Body");  Luschka's  (see  "Coccygeal 
Body"). 

Glands,  inguinal,  relation  of,  to  lym- 
phatics of  rectum,  16;  lumbar,  rela- 
tion of,  to  lymphatics  of  rectum,  16; 
of  rectum,  12;  sacral,  relation  of,  to 
lymphatics  of  rectum,  16;  solitary, 
of  rectum,  4. 

Gonococcus  in  feces,   61;   staining  of,   175. 

Gonorrhea,  a  cause  of  ano-rectal  ulcer, 
223;  diagnosis  of,  177;  etiology  of, 
175;  literature  on,  188;  Neisser's  gon- 
ococcus of,  175;  prognosis  of,  177;  a 
cause  of  stricture,  354;  symptoms  of, 
176;  treatment  of,  179. 

Gram's  method  in  staining  gonococcus, 
175. 

Growths,  malignant,  differential  diagnosis 
from  prolapse,  388;  from  hemorrhoids, 
426. 

Gumma,  differential  diagnosis  from  car- 
cinoma, 531. 

Gummata,  185;  as  cause  of  rectal  ulcera- 


INDEX 


Gummata  (concluded) 

tion,  322;  symptoms  and  diagnosis  of, 
186;  treatment  of,  186. 

Hairy  concretions  in  rectum,  636. 

Headache  in  auto-intoxication,   127. 

Head-mirror  in   examination,   43. 

Hegar's  method  for  Kraske  operation,  548. 

Heincke's  method  for  Kraske  operation, 
546. 

Hemorrhage,  method  of  arresting,  476; 
astringents  in,  480;  cauterization  in, 
480;  in  chancres  and  chancroids,  474; 
clamping  in,  480;  in  condylomata, 
474;  diagnosis  of,  475;  etiology  of, 
473;  in  fecal  impaction,  474;  feces  in, 
53;  in  anal  fissure,  301,  474;  in  hem- 
orrhoids, 424,  473;  hot  water  in,  480; 
ice-water  in,  480;  intravenous  infu- 
sion in,  481;  in  malignant  disease,  474; 
in  non-malignant  ulcer,  332;  in  rec- 
tal operations,  474;  from  rectum,  35; 
in  polypus,  474;  pressure  in,  477;  pri- 
mary, 475;  in  proctectomy,  574;  in 
proctitis,  474;  profuse,  476;  pathology 
of,  475;  recurrent,  475;  secondary,  475; 
from  stomach,  evacuated  from  rec- 
tum, 36;  in  stricture,  474;  styptics 
in,  480;  symptoms  of,  475;  torsion  in, 
480;  in  traumatism,  474;  in  typhoid 
fever,  70;  in  ulcer,  474. 

Hemorrhoids,  age  in,  410;  in  anal  fissure, 
296,  317;  In  auto-intoxication,  126; 
carbolic-acid  injection  in,  468;  classi- 
fication of,  409;  constipation  in,  412; 
a  symptom  of  constipation,  93;  cuta- 
neous, 422;  differential  diagnosis  of, 
306,  388;  etiology  of,  410;  external, 
409;  heredity  in,  410;  history  of,  408; 
internal,  410;  internal  hemorrhage  in, 
473;  ligature  operation  in,  470;  occu- 
pation in,  411;  non-surgical  treatment 
of,  430;  pathology  of,  412;  position 
in,  412;  prolapse  of,  473;  sex  in,  410; 
surgical  treatment  of,  433;  thrombotic, 
4'i'2  ;  tight  lacing  in,  411  ;  truss  for,  433. 
external,  409;  cutaneous,  409,  417,  418, 
421,  422;  diagnosis  of,  419;  illustrative 
cases,  422;  operative  treatment  of, 
421;  non-operative  treatment  of,  419; 
post-operative  treatment  of,  422; 
symptoms  of,  418;  thrombotic,  409, 
416,  418,  421,  422. 
internal,  410;  astringents  in,  455;  capil- 
lary, 410,  416;  carbolic-acid  injections 
in,  468;  cauterization  in,  455,  463; 
clamp-and-cautery  operation  in,  436, 
470;  crushing  method  in,  465;  diag- 
nosis of,  426;  differential  diagnosis  of, 
426,  427;  divulsion  of  sphincter  in, 
464;  Earle's  operation  in,  453;  ecra- 
Beur  method  in,  466;  excision  in,  448; 


hemorrhage   in,    424,    473;    illustrativa 
cases,  468;  Injection  of  fluids  in,   455, 
468;  ligature  operation  for,  445;  litera- 
ture  of,    471;    Martin's   operation   for, 
444;  operations  for,  436;  pain  in,  425 
Pennington's  operation  for,  455;  prep 
aration   of   patient   for   operation   for, 
434;    prognosis   of,    428;    Rickets's   op 
eration  for,  461;  spontaneous  cure  of, 
429;  submucous  ligation  of,  461;  symp- 
toms  of,    424;    treatment   of,    429;    ve 
nous,  410;  Whitehead's  operation  for, 
449,  451. 

Heredity,  theory  of,  in  carcinoma,  509 
in  hemorrhoids,   410. 

History  chart,  card-index,  40. 

Hochenegg's  modification  of  Kraske  op- 
eration, 549. 

Houston's  "valves,'  10,  12,  19,  20;  in 
stricture,  356.  (See  also  "Valves," 
Houston's.) 

Hyperesthesia,  rectal,  diagnosis  of,  631; 
etiology  of,  631;  illustrative  case,  634; 
symptoms   of,   631;    treatment  of,   632. 

Hyrtl,  on   "rectal  valves,"  21. 

Hysterical  rectum.  (See  "Hyperesthe- 
sia.") 

Ice-water  in  hemorrhage,  480. 

Icterus  catarrhalis,  feces  in,  66. 

Ileum,  bile  in,  62. 

Ileus,   paralytic,   cause  of,   110. 

Impaction,  fecal,  age  in,  114;  cause  of, 
38,  108,  115;  diagnosis  of,  110,  111; 
diarrhea  as  result  of,  142;  differentia- 
tion of,  from  cancer,  HI;  hemorrhage 
in,  474;  location  of,  115;  pathology  of, 
108;  prognosis  of,  112;  sex  in,  114; 
symptoms  of,  109;  synopsis  of,  116, 
117,  118,  119;  treatment  of,  112; 
weight,   115. 

Imperforate  rectum.  (See  "Rectum,  Im- 
perforate.") 

Incision  in  non-malignant  ulcers,  illustra- 
tive case,  344;  exploratory,  in  exami- 
nation,  51. 

Incontinence,  fecal,  artificial  anus  in,  292; 
Bailey's  method  of  preventing,  in  co- 
lostomy, 611;  Bernays's  method  of  pre- 
venting, in  colostomy,  612;  Braune'a 
method  of  preventing,  in  colostomy, 
613;  cause  of,  260,  286;  Chetwood's  op- 
eration in,  292;  definition  of,  286; 
diagnosis  of,  288;  etiology  of,  260,  286; 
in  anal  fistula,  245,  249,  260,  262; 
Gant's  method  of  preventing,  in  co- 
lostomy, 614;  Gersuny's  method  of 
preventing,  in  colostomy,  613;  illus- 
trative case,  292;  literature  of,  293; 
pathology  of,  286;  following  proc- 
tectomy, 375,  560,  575;  prognosis  of, 
289;  Schinzinger's  method  of  prevent- 


INDEX 


689 


Incontinence,   fecal   (concluded). 

ing,  in  colostomy,  611;  symptoms  of, 
288;  treatment  of,  290,  560;  varieties 
of,  286;  Weir's  method  of  preventing, 
in  colostomy,  611;  Witzel's  method 
of  preventing,  in  colostomy,  612; 
"Wyeth's  method  of  preventing,  in 
colostomy,  613. 

fndican  in  urine,  a  symptom  of  auto- 
intoxication, 125;  test  for,  125. 

Indigestion,  a  cause  of  rectal  disturbance, 
38. 

Induration,  a  symptom  of  rectal  disturb- 
ance, 39. 

Infancy,   anal  fissure  in,   304. 

Infants,  structure  of  colon  in,  7. 

Infection,  auto-.  (See  "Auto-intoxica- 
tion.") 

Infection   following   proctectomy,   574. 

Inflammation,  catarrhal,  as  cause  of 
stricture,  354;  in  rectum,  cause  of, 
37. 

Infusion,  intravenous,  in  hemorrhage,  481. 

Infusoria  in  chronic  diarrhea,  60. 

Injections,  astringent,  in  hemorrhoids, 
455;  caustic,  in  hemorrhoids,  455;  in 
anal  fistula,  252;  in  hemorrhoids,  455, 
468;  hypodermic,  in  prolapse,  392;  in 
non-malignant  ulcer,  337.  (See  also 
"Enemata.") 

Injuries  to  rectum,  647;  literature  of,  652; 
symptoms  of,  649;  treatment  of,  650. 

Inspection   in   examination,   51. 

Instruments  in  examination,  42;  for  anal 
fistula  operation,  251. 

Insufflator,   336. 

Intermural  abscess,   226. 

Intestine,  anatomy  of,  3;  auto-intoxica- 
tion from  (see  "Auto-intoxication"); 
blood-supply  of,  4;  calculi  of,  635, 
637;  carcinoma  of,  differential  diag- 
nosis from  impaction,  111;  catarrh  of, 
character  of  feces  in,  62,  63;  concre- 
tions of,  635  (see  also  "Enteroliths"); 
diverticula  of,  5;  intussusception  of, 
feces  in,  72;  invagination  of,  388;  lym- 
phatics of,  4;  mesocolon  of,  5;  mu- 
cosa of,  atrophy  of,  66;  nerve-supply 
of,  5;  sacculations  of,  4;  solitary 
glands  of,  4;  structure  of,  in  infants, 
7;  tuberculosis  of,  feces  in,  67. 

Intussusception  of  colon  and  sigmoid  into 
rectum,  387;  differential  diagnosis 
from  prolapse,  388;  feces  in,  72. 

Invagination  of  colon  and  sigmoid  into 
rectum,  387;  differential  diagnosis 
from  prolapse,  388. 
rectal,  proctectomy  by,  570;  method  of 
Steinthal,  571;  method  of  Maunsell, 
571. 

Irregularities  in  living,  a  cause  of  rectal 
disease,  602. 


Irrigator,  artificial,  Barger's,  113;  rectal, 
Kemp's,  216;  Sims's  rectal  and  drain- 
age, 336. 

Itching,  in  non-malignant  ulcer,  333.  (See 
also   "Pruritus.") 

Jaennel's    method    for    Kraske    operation, 

547. 
Jarring  motion,  a  cause  of  rectal  disease, 

666. 

Keen's  modification  of  Kraske  operation, 
550. 

Kelene  in  examination,  49. 

Kelly's  operation  for  colo-proctostomy, 
573;  pad,  modified,  114. 

Kelsey,  rectal  retractor,  334;  on  "rectal 
valves,"  22;  method  of  forming  spur 
in  colostomy,   608. 

Kemp's  rectal  irrigator,  216. 

Kleberg's  bloodless  operation  for  pro- 
lapse,  402. 

Koch-Ehrlich  solution,  for  staining  gono- 
coccus,   176. 

Kocher's  modification  of  Kraske  opera- 
tion, 547. 

Kohlrausch's  plicae  transversalis  recti,  19. 

Kraske  operation,  554.  (See  also  "Proc- 
tectomy,   Superior.") 

Labial  abscess,   227. 

Lange's  modification  of  Kraske  operation, 
550;  operation  for  prolapse,  397. 

Laparo-proctectomy,   569. 

Le  Roy  indestructible  cautery,  404. 

Leprosy,  a  cause  of  rectal  ulcer,  331. 

Leucocytosis  in  rectal  disease,  51. 

Levy's  modification  of  Kraske  operation, 
548. 

Lieberkiihn,   crypts  of,  4,   12. 

Ligation,  in  anal  fistula,  253;  in  closure  of 
artificial  anus,  622;  in  polypus,  498, 
499;  in  rectal  hemorrhage,  477;  in  tu- 
bercular fistula,  282. 
submucous,  in  hemorrhoids,  461;  for 
prolapse,  403. 

Ligature,  application  of,  in  hemorrhoids, 
445,   447,   461,   470. 

Light  in   examination,   43. 

Linea  dentata  in  rectum,  12. 

Lipoma  of  rectum,  487;  differential  diag- 
nosis from  sarcoma,  532. 

Lisfranc's  operation  for  proctectomy,  544, 
551. 

Littre's  operation  of  inguinal  colostomy, 
87. 

Liver,  cirrhosis  of,  feces  in,  67;  degen- 
eration of,   feces  in,  67. 

Loeffler's  solution  for  staining  tubercle 
bacilli,  68. 

Lungs,  tuberculosis  of,  relation  to  anal 
fistula,  275. 


690 


INDEX 


Lupus   exedens,   339. 

Luschka's  gland.    (See  "Coccygeal  Body.") 
Lymphatics  of  colon,  4;  of  rectum,  16;  of 
rectum,  relation  to  rectal  glands,   16. 
Lymphosarcoma,  523. 


Malformations,  congenital,  of  rectum  and 
anus,  73;  diagnosis  of,  79;  prognosis 
of,  81;  symptoms  of,  78;  treatment  of, 
83. 

Malignant  disease,  hemorrhage  in,  474; 
growths,  differential  diagnosis  of,  388, 
426;   literature  or,  377;  rectal,  502. 

Marginal  abscess,  226. 

Martin's  clamp,  442;  operation  for  consti- 
pation, 105;  operation  for  hemor- 
rhoids, 444;  on  "rectal  valves,"  23; 
operation  of  "valvotomy,"   105. 

Massage  in  constipation,  95,  97;  effect  of, 
98. 

Masturbation,   rectal,  187,   658. 

Mathews's  fistulatome,  255;  pile-forceps, 
445;  method  of  forming  spur  in  co- 
lostomy, 609;  operation  for  prolapse, 
403;  on  "rectal  valves,"  23. 

Maunsell's  operation  of  proctectomy,  571. 

Maydl's  method  of  forming  spur  in  co- 
lostomy, 608. 

McLeod's   operation   for   prolapse,   399. 

Melancholia,   in   anal   fissure,   302. 

Mesocolon  of  intestine,  5;   anatomy  of,  7. 

Metastases  in  carcinoma  and  sarcoma,  527. 

Method  of  opening  abdominal  wall  in  co- 
lostomy, 602;  of  closing  artificial 
anus,  620,  622;  of  dealing  with  the 
bowel  in  Kraske  operation,  559;  of 
dilatation  of  sphincter,  435;  of  closing 
fecal  fistula,  623;  of  forming  flap  in 
superior  proctectomy,  558;  for  stain- 
ing gonococcus.  Gram's,  175;  for 
staining  gonococcus,  Koch-Ehrlich, 
176;  of  crushing,  in  hemorrhoids, 
465;  ecraseur,  in  treatment  of  hemor- 
rhoids, 466;  injection,  in  hemorrhoids, 
458;  of  preventing  fecal  incontinence 
in  colostomy,  610;  of  arresting  hem- 
orrhage, 476;  ligature,  in  hemor- 
rhoids, 441;  of  packing  rectum,  478; 
of  dealing  with  peritoneum  in  co- 
lostomy, 602;  of  preparing  patient 
for  proctectomy,  542;  osteo-integu- 
mentary  flap,  558;  for  staining  tuber- 
cle bacilli,  Ziehl-Neelson's,  68. 
Allingham's,  for  forming  spur  in  co- 
lostomy, 607. 
Bailey's,  for  preventing  fecal  inconti- 
nence in  colostomy,  611. 
Bardenheuer's,     for     Kraske     operation, 

546. 
Bernays's,   for  preventing  fecal  inconti- 
nence in  CO. ostomy,  612. 


Bodine's,  of  forming  spur  in  colostomy, 
609. 

Borelius's,  for  Kraske  operation,  549. 

Braune's,  for  preventing  fecal  inconti- 
nence in  colostomy,   613. 

Gant's,  of  opening  bowel  in  colostomy, 
606;  of  closing  artificial  anus,  620;  of 
coccygogectomy,  157;  for  constipa- 
tion, 104;  for  clamping,  621;  for  pre- 
venting fecal  incontinence  in  co- 
lostomy, 614;  for  Kraske  operation, 
555;  for  osteo-integumentary  flap, 
558;  for  "valvotomy,"  104. 

Gersuny's,  for  Kraske  operation,  550; 
for  preventing  fecal  incontinence  in 
colostomy,  613. 

Gram's,  for  staining  gonococcus,  175. 

Hegar's,  for  Kraske  operation,  548. 

Heincke's,    for   Kraske   operation,    546. 

Hochenegg's,  for  Kraske  operation,  549. 

Jaennel's,   for  Kraske   operation,   547. 

Keene's,   for  Kraske  operation,  550. 

Kelsey's,  for  forming  spur  in  colostomy, 
608. 

Koch-Ehrlich,  for  staining  gonococcus, 
176. 

Kocher's,   for  Kraske  operation,  547. 

Lange's,  for  Kraske  operation,  550. 

Levy's,  for  Kraske  operation,  548. 

Martin's,  for  "valvotomy,"  105. 

Mathews's,  for  forming  spur  in  co- 
lostomy,   609. 

Maydl's,  for  forming  spur  in  colostomy, 
608. 

Morestin's,  for  Kraske  operation,  550. 

Nott's,   for  coccygogectomy,   150. 

Paul's,  for  opening  bowel  in  colostomy, 
605. 

Pennington's,    for   hemorrhoids,    455. 

Rehn-Rydygier's,  for  Kraske  operation, 
547. 

Robson's,  for  opening  bowel  in  co- 
lostomy,  607. 

Roux's,  for  Kraske  operation,  549. 

Schinzinger's,  for  preventing  fecal  in- 
continence in  colostomy,   611. 

Simpson's,  tenotomy  for  coccygodynia, 
156. 

Walker's,    for   Kraske   operation,    549. 

Weir's,  for  preventing  fecal  incontinence 
in  colostomy,  611;  of  forming  spur  in 
colostomy,  608. 

Wetzel's,  for  preventing  fecal  inconti- 
nence in  colostomy,  612. 

Willems's,    for   Kraske   operation,    551. 

Wolfler's,  for  Kraske  operation,  549. 

Wyeth's,  for  preventing  fecal  inconti- 
nence in  colostomy,  610. 

Ziehl-Neelsen's,  for  staining  tubercle 
bacilli,  68. 

Zuckerkandl's,  for  Kraske  operation, 
549. 


INDEX 


691 


Meyer,  on  relation  of  phthisis  pulmonalis 
to  anal  fistula,  276. 

Microscopic  examination  in  malignant 
growths,  532;  of  feces,  52,  55. 

Micturition,  relation  of  levator  ani  mus- 
cle to,  17. 

Mirror  in  examination,  44. 

Mikulicz's  operation  for  prolapse,  401. 

Mixed  treatment  in  rectal  stricture,  366. 

Morestin's  method  for  Kraske  operation, 
550. 

Morgagni,  columns  of,  13. 

Mortality  in  proctectomy,   562. 

Mucosa,  intestinal,   atrophy  of,  66. 

Mucous  membrane  of  colon,  4;  rectal  pro- 
lapse of,  385. 
patches  In  rectum,  321. 

Mucus  in  feces,  53,  61,  64;  in  feces  of 
dysentery,  69;  indication  of,  in  rec- 
tum, 36. 

Muscles,  corrugator  cutis  ani,  16;  detrusor 
faecium,    21;    external    sphincter,    16; 
internal  sphincter,  12,  17;  of  rectum, 
16,   17. 
levator    ani,     17;    voluntary    action    of, 
after  division  of  sphincter,  17;  action 
of,   in   defecation,    17;    division   of,    in 
constipation,   103;   relation  of,   to  rec- 
tum, 17;  relation  of,  to  urination,  17; 
tenotoniy  of,   in  constipation,   102. 
recto-coccygeus,  17;  action  of,  in  defeca- 
tion, 17. 
sphincter  ani,  action  of  levator  ani  mus- 
cle after  division  of,   17. 
sphincter  ani  tertius,  21. 
transversus    perinei,    16;    action    of,    in 
defecation,   17. 

Myoma  of  rectum,  492. 

Myxoma  of  rectum,  494. 

Necrosis  of  coccyx,   160. 

Needle,   aspirating,   in  examination,   47. 

Nelaton,  on  "rectal  valves,"  21;  operation 
for  stricture,  371. 

Neoplasms,  malignant.  (See  "Carcinoma" 
and  "Sarcoma.") 

Nerve,  pudic,  relation  of,  to  genito-uri- 
nary  organs,  15;  supply  of  colon,  5; 
supply  controlling  defecation,  30; 
supply  of  rectum,  15. 

Nerve-ache,  625.     (See  "Neuralgia.") 

Nervous  system,  condition  of,  in  auto- 
intoxication, 126. 

Nervousness  in  anal  fissure,  302. 

Neuralgia  of  rectum,  a  cause  of  constipa- 
tion, 94;  in  auto-intoxication,  127; 
diagnosis  of,  627;  differential  diag- 
nosis from  anal  fissure,  306;  etiology 
of,  625;  Illustrative  case,  632;  litera- 
ture of,  634;  pathology  of,  625;  prog- 
nosis of,  627;  symptoms  of,  626;  treat- 
ment of,  626. 


Neurosis,   secretion.     (See  "Colo-proctitis, 

Membranous.") 
Nevus  of  rectum,  490. 

Nitric  acid  in  treatment  of  prolapse,   392. 
Nitrous-oxide  gas  in  colostomy  operation, 

601;  in  examination,  49. 
Non-malignant   tumors.      (See   "Polyps.") 
Nott's  operation  of  coccygogectomy,  156. 

Oat-stones,  rectal,  636. 
O'Beirne,  sphincter  of,  29. 
Obstruction,  mechanic,  a  cause  of  consti- 
pation,   90;    in   rectum,    cause   of,    37; 
"valvular,"  forms  of,  24. 
Occupation  in  hemorrhoids,  411. 
Odor,    a    symptom    of   rectal    disturbance, 

38. 
Ointment     applicator,     Allingham's,     337; 

syringe,   Gant's  recto-colonic,   337. 
Omentum  colicum,  5;  gastro-colic,  5. 
Onanism,    rectal,    658;    disease   caused   by, 

187. 
Operability  in  proctectomy,  562. 
Operation    for    congenital    malformations, 
84;     a    cause    of    pruritus    ani,     192; 
preparation    of    patient    for,    251;    for 
vaginal   proctectomy,    565. 

Allingham's,  for  forming  spur  in  co- 
lostomy, 608. 

Bacon's,  for  stricture,  376. 

Bailey's,  for  preventing  fecal  inconti- 
nence in  colostomy,  611. 

Bardenheuer's  modification  of  Kraske, 
546. 

Bean's,   for  prolapse,  394. 

Bernays's,  for  preventing  fecal  inconti- 
nence in  colostomy,  612. 

Bodine's,  for  forming  spur  in  colostomy, 
609. 

Borelius's  modification  of  Kraske,  549. 

Boyer's,   for  anal  fissure,  314. 

Braune's,  for  preventing  fecal  incon- 
tinence in   colostomy,    613. 

Chetwood's,  for  fecal  incontinence,  292; 
clamp  and  cautery,  436,  470. 

Dupuytren's,  for  prolapse,  395. 

Earle's,   for  hemorrhoids,   453. 

Edebohls's  proctectomy  per  vaginam, 
572. 

Fowler's,  for  prolapse,  398,  402. 

Gant's,  for  artificial  anus,  621;  anasto- 
mosis and  resection,  622;  coccygogec- 
tomy, 157;  colostomy,  606;  for  con- 
stipation, 104;  for  internal  hemor- 
rhoids, 436;  osteo-integumentary  flap, 
558;  for  prolapse,  394,  395,  400;  for 
"valvotomy,"  104. 

Gersuny's  modification  of  Kraske,  550. 

Hegar's  modification  of  Kraske,  548. 

Heincke's  modification  of  Kraske,  546. 

Hochenegg's  modification  of  Kraske, 
549. 


692 


INDEX 


Operation  (concluded). 

Jaennel's  modification  of  Kraske,   547. 

Keene's   modification   of   Kraske,    550. 

Kelly's,   for  colo-proctostomy,   573. 

Kelsey's,  for  forming  spur  in  colostomy, 
608. 

Kleberg's  bloodless,   for  prolapse,   402. 

Kocher's  modification  of  Kraske,  547. 

Kraske's,  for  superior  proctectomy,  545, 
554. 

Lange's  modification  of  Kraske,  550;  for 
prolapse,  397;  ligature  for  hemor- 
rhoids,  434,   445,    470. 

Levy's  modification  of  Kraske,   550. 

Lisfranc's,    for  proctectomy,   544,    551. 

Martin's,  for  hemorrhoids,  444;  of  "val- 
votomy,"  105. 

Mathews's,  for  prolapse,  403;  for  form- 
ing spur  in  colostomy,  609. 

Maunsell's,   for  proctectomy,  571. 

McLeod's,   for  prolapse,   399. 

Mikulicz's,  for  prolapse,  401. 

iviorestin's  modification  of  the  Kraske, 
550. 

Nelaton's,  for  stricture,  371. 

Nott's,  for  coccygogectomy,  156. 

Paul's,  for  colostomy,  605. 

Pennington's,   for  hemorrhoids,  455. 

Recamier's,  for  anal  fissure,  313. 

Rehn-Rydygier's  modification  of  Kraske, 
547. 

Rickets's,  for  hemorrhoids,  461;  for  pro- 
lapse, 403. 

Roberts's,  for  prolapse,  397. 

Robson's,  for  colostomy,  607. 

Roux's  modification  of  Kraske,  549. 

Schinzinger's,  for  preventing  fecal  in- 
continence in  colostomy,  611. 

Simpson's,    for  coccygogectomy,   156. 

Steinthal's  proctectomy  by  invagination, 
571. 

Treves's,  for  prolapse,  402. 

Tuttle's,  for  fistula  in  ano,  266. 

Urbane's,  for  prolapse,  394. 

"V^an  Buren's,  for  prolapse,  394. 

Verneuil's,   for  prolapse,   397. 

Walker's  modification  of  Kraske,  549. 

Weir's,  for  forming  spur  in  colostomy, 
608;  for  preventing  fecal  incontinence 
in   colostomy,   611. 

Wetzel's,  for  preventing  fecal  inconti- 
nence in  colostomy,  612. 

Whitehead's,  for  hemorrhoids,  449. 

Willems's  modification  of  Kraske,  551. 

Wolfler's  modification  of  Kraske,  549. 

Wyeth's,  for  preventing  fecal  inconti- 
nence in   colostomy,   613. 

Zuckerkandl's    modification    of    Kraske, 
549. 
Operations,   rectal,   hemorrhage  from,   474. 
Osteo-integumentary    flap    in    Kraske    op- 
eration,   658. 


Osteoma,  rectal,  494. 

Otis,  on  "rectal  valves,"  21. 

Packing  of  rectum,  478. 

Pain  m  anal  fissure,  300,  309;  in  ano- 
rectal fistula,  244;  in  hemorrhoids, 
425;  localization  of,  in  rectum,  15; 
in  rectal  region,  34;  after  proctec- 
tomy, 574;  in  non-malignant  ulcer, 
332. 

Palpation  in  examination,  50. 

Pancreatic  calculi,  rectal,  638. 

Papillae  of  rectum,  13. 

Papilloma,   rectal,   183,   488. 

Paquelin  cautery,  improved,  439. 

Parasite  theory  for  carcinoma,  507. 

Parasites  in  chronic  diarrhea,  60;  in  feces, 
59. 

Park,  on  bacillus  coli  communis,  130, 
133. 

Patches,  mucous,  181;  in  ano-rectal  ulcer, 
321. 

Patient,  preparation  of,  for  operation,  251, 
434;  position  of,  in  operation,  47,  48; 
position  of,  in  hemorrhoid  operation, 
437. 

Paul's  operation  for  colostomy,  605. 

Pecten  of  rectum,  12. 

Pederasty,  176,  187;  manner  of  acquiring, 
656;  history  of,  653;  physical  signs  of, 
655;  literature  of,  6.58. 

Pelvic  fioor,   formation  of,   17. 

Pennington's  operation  for  hemorrhoids, 
455;  on   "rectal  valves,"  24. 

Percussion  in  examination,  50. 

Perineal  excision  of  rectum,  562.  (See 
also  "Proctectomy.") 

Periproctitis,  colon  bacillus  in,  133;  a 
cause  of  constipation,  94;  diagnosis 
of,  228;  etiology  of,  224;  relation  of, 
to  fistula  in  ano,  236;  literature  of, 
232;  pathology  of,  224;  prognosis  of, 
227;  symptoms  of,  228;  treatment  of, 
229;  varieties  of,  225. 

Peristalsis,  defective,  a  cause  of  constipa- 
tion, 91. 

Peritoneum,  relation  tf,  to  rectum,  11; 
treatment  of,  in  colostomy,  602. 

Peritonitis  in  stricture,  360. 

Pessaries  In  prolapse,  392. 

Phthisis  pulmonalis,  relation  of,  to  anal 
fistula,  250,  275. 

Physiology  of  rectum  and  sigmoid  colon, 
29. 

Pile,    "sentinel,"    302. 

Piles,  408  (see  also  "Hemorrhoids");  itch- 
ing,  190   (see  also   "Pruritus  Ani"). 

Plexus,  the  hemorrhoidal,  10. 

Plicse  transversalis  recti,  Kohlrausch's, 
19. 

Pockets  of  rectum,  13. 

Pollock's  hemorrhoidal  crusher,  464. 


INDEX 


693= 


Polyp,  rectal,  4S3;  adenoid,  495;  adenom- 
atous, 484;  angiomatous,  490;  a  cause 
of  constipation,  92;  clamp  and  cau- 
tery for,  498,  500;  cystomatous,  492; 
diagnosis  of,  496;  a  cause  of  diarrhea, 
142;  enchondromatous,  492;  fibroma- 
tous,  4SS,  495;  glandular,  484;  hard, 
495;  hemorrhage  in,  474;  illustrative 
case,  499;  ligation  in,  498,  499;  lipom- 
atous,  487;  literature  of,  501;  myom- 
atous, 492;  myxomatous,  494;  osteoid, 
494;  papillomatous,  488;  prognosis  of, 
497;  soft,  495;  snare  for,  498;  status 
lympliaticus  in,  485;  symptoms  of, 
495;  treatment,  of,  146,  497;  varieties 
of,   484. 

differential  diagnosis  of,  from  adenocar- 
cinoma,    496;     from     carcinoma,     531; 
from  hemorrhoids,  427;  from  prolapse, 
388. 
Position    of   patient,    47,    48;    in    operation 
for   hemorrhoids,    412,    437;    genu-pec- 
toral,    48;    knee-chest,    47;    lithotomy, 
48;  semipronc,  48;   Sims's,  48. 
Pressure  in  rectal  hemorrhage,   477. 
Probe,   Gant's,  258;   in  examination,   47. 
Procidentia  recti.     (See  "Prolapse.") 
Proctectomy,      after-treatment      of,      561; 
cause  of  death  in,  577;   complications 
in,    573;    hemorrhage   in,    574;    history 
of,   543;   fecal   incontinence  following, 
560,    575;    infection    following,   574;    by 
invagination,  570;  laparo-,  569;  litera- 
ture   of,    577;    for   malignant   disease, 
540,  543;  pain  following,  574;  perineal, 
543,    551;    preparation  .  of   patient   for, 
542;    permanent    results    in,    575;    se- 
quels of,  573;  stricture  following,  574; 
varieties   of,    543;    vesical   disturbance 
in,     574.       (See     also     "Method"     and 
"Operation.") 

Allingham's  operation  for,  551;  Barden- 
heuer's,  546;  Borelius's,  549;  Ede- 
bohls's,  572;  Gant's,  555;  Gersuny's, 
550;  Hegar's,  548;  Heincke's,  546; 
Hochenegg's,  549;  Jaennel's,  547; 
Keene's,  550;  Kocher's,  547;  Kraske's, 
545,  554;  Lange's,  550;  Levy's,  548; 
Lisfranc's,  544;  Maunsell's,  571;  More- 
stin's,  550;  Rehn-Rydygier's,  547; 
Roux's,  549;  Steinthal's,  571;  Walk- 
er's, 549;  Willems's,  551;  Wolfler's, 
549;    Zuckerkandl's,    549. 

celio-,  569. 

inferior,  543;  Allingham's  incision  in, 
551;  Lisfranc's  operation  for,  551; 
mortality  in,   562;   operability   in,   562. 

invagination,  570;  Maunsell's  method  in, 
571;  Steinthal's  method  in,  571. 

laparo-,  569. 

superior,  543;  Kraske  operation  for,  545, 
554;  mortality  in,  562;  operability,  562. 


vaginal,    565;    Edebohls's    operation    for, 
572. 

Proctitis  in  anal  fissure,  301;  a  cause  of 
ano-rectal  ulcer,  324;  atrophic,  211; 
catarrhal,  207;  character  of  feces  in, 
32,  63,  64;  a  cause  of  constipation, 
94;  colon  bacillus  in,  133;  a  cause  o( 
diarrhea,  140;  chronic  diarrhea  in, 
140;  diphtheritic,  208;  dysenteric,  207; 
erysipelatous,  208;  hemorrhage  in, 
474;  hypertrophic,  211;  literature  of, 
222;  stenosing,  212;  treatment  of,  144. 
acute,  diagnosis  of,  208;  etiology  of,  207; 
pathology  of,  207;  symptoms  of,  208; 
treatment  of,  209;  varieties  of,  207. 
chronic,  140;  diagnosis  of,  212;  etiology 
of,  211;  palliative  treatment  of,  213; 
pathology  of,  211;  prognosis  of,  213; 
surgical  treatment  of,  216;  symptoms 
of,  212;  varieties  of,  207. 
gonorrheal,  208;  cause  of,  175;  diagnosis 
of,  177;  prognosis  of,  177;  symptoms 
of,  176;  treatment  of,  177. 

Proctopexy  for  prolapse,  398. 

Proctoplasty,  84;  in  stricture,  375;  in- 
ferior, for  prolapse,  395. 

Proctoscope,  45;  manipulation  of,  47;  in 
examination  for  stricture,  363;  Tut- 
tle's,  46. 

Proctostomy,  colo-,  573. 

Proctotomy,  external,  for  stricture,  371, 
380;  internal,  for  stricture,  371,  377; 
Nelaton's  operation  of,  for  stricture, 
371;   posterior,    for   stricture,   371,   377. 

Prolapse,  amputation  for,  400,  406;  Bean's 
operation    for,    394;    cauterization    in, 

392,  394,  404,  405;  classification  of,  398; 
of  colon  into  lower  rectum,  387;  after 
colostomy,  589,  616;  colopexy  for,  398; 
complete,  386;  complications  of,  389; 
diagnosis  of,  387;  a  cause  of  diarrhea, 
141;  Dupuytren's  operation  for,  395; 
etiology  of,  383;  excision  for,  400,  406; 
Fowler's  operation  for,  398,  402;  gan- 
grene   in,    389;    Gant's    operation    for, 

393,  394,  400;  hemorrhage  in,  473; 
hypodermic  injections  in,  392;  illus- 
trative cases,  404;  Kleberg  s  bloodless 
operation  for,  402;  Lange's  operation 
for,  397;  literature  of,  407;  Mathews's 
operation  for,  403;  McLeod's  opera- 
tion for,  399;  of  mucous  membrane, 
3S5;  nitric  acid  in,  392;  non-operative 
treatment  in,  390;  partial,  385;  pa- 
thology of,  384;  pessaries  in,  392; 
posterior  proctoplasty  for,  395;  prog- 
nosis of,  390;  protrusions  from  anus, 
34;  of  all  rectal  coats,  3s6;  rectopexy 
for,  398;  of  upper  rectum  into  lower 
rectum,  387;  reduction  of,  391;  Rick- 
ets's  operation  for,  403;  Roberts's  op- 
eration for,  397;  of  sigmoid  into  lower 


694 


INDEX 


Prolapse  (concluded). 

rectum,  387;  sigmoidopexy  for,  398; 
strapping  in,  392;  strychnine  in,  392; 
submucous  ligation  for,  403;  surgical 
treatment  of,  393;  symptoms  of,  389; 
treatment  of,  146;  Treves's  operation 
for,  402;  trusses  in,  392;  a  symptom 
of  ulceration,  93;  Urbane's  operation 
for,  394;  Van  Buren's  operation  for, 
394;  varieties  of,  382;  ventral  fixation 
for,  399;  Verneuil's  operation  for,  397. 
differential  diagnosis  from  hemorrhoids, 
388,  427;  from  intussusception,  388; 
from  invagination,  388;  from  malig- 
nant growths,  388;  from  polypus,  388. 

Prolapsus  ani.     (See   "Prolapse.") 

Prostatic  calculi,   639. 

Pruritus  ani,  cause  of,  36;  differentia] 
diagnosis  from  hemorrhoids,  427;  eti- 
ology and  pathology  of,  190;  in  anal 
fissure,  301;  in  fistula  in  ano,  244; 
illustrative  case,  206;  literature  of,  206; 
surgical  treatment  of,  205;  symptoms 
and  diagnosis,  194;  treatment  of,  197; 
in  non-malignant  ulcer,  333. 

Pus  in  feces,  62,  65,  70;  in  ano-rectal 
fistula,  244;  in  rectum,  36;  in  tuber- 
cular fistula,  244. 

I^ailroading,  a  causative  factor  in  rectal 
disease,   660;  tables  on,  667,   669. 

Rashes  following  enemata,  99. 

Reaction  of  feces,  54. 

Recamier's  operation  for  anal  fissure,  313. 

Rectal  chambers,  the,  10. 

Rectal  diseases.  (See  "Diseases,  Rec- 
tal.") 

"Rectal  valves."  (See  "Valves,  Hous- 
ton's.") 

Rectitis,   470.     (See   "Proctitis.") 

Rectopexy  in  prolapse,  398. 

Rectum,  absorption  by  mucous  membrane 
of,  13;  abdomino-perineal  excision  of, 
569;  adenoma  of,  484;  amputation  of, 
400;  ampulla  of,  8,  10;  anatomy  of, 
8;  angioma  of,  490;  arteries  of,  14; 
blood-supply  of,  14;  boundaries  of, 
7,  9;  cancer  of,  feces  in,  72;  catarrh 
of  (see  "Proctitis");  congenital  mal- 
formations of  (see  "Malformations, 
Congenital");  chancres  of,  321;  chan- 
croids, 322;  concretions  of  (see  "En- 
teroliths"); crypts  of  Lieberkuhn  in, 
12;  cystoma  of,  492;  dermoid  cyst  of, 
491;  condition  of,  in  chronic  diarrhea, 
142;  dilatation  of,  38;  discharges  from, 
in  disease,  36;  direction  of,  8,  9;  ordi- 
nary seat  of  disease  in,  9;  divisions 
of,  10;  enchondroma  of,  492;  absorp- 
tion of  enemata  in,  32;  enteroliths  of 
(see  "Enteroliths");  epithelium  of, 
12;     transitional     epithelium     in,     12; 


aversion  of,  50;  examination  of,  41; 
excision  of,  569,  570,  571  (see  also 
"Proctectomy");  fibroma  of,  488;  fist- 
ula of  (see  "Fistula,  Ano-rectal"); 
gummata  of,  322;  hemorrhage  from 
(see  "Hemorrhage");  hyperesthesia 
of  (see  "Hyperesthesia");  hysterical 
(see  "Hyperesthesia");  intussuscep- 
tion of  colon  and  sigmoid  into,  387; 
invagination  of  colon  and  sigmoid 
into,  387;  literature  on  malignant 
growths  of,  577;  lipoma  of,  487;  malig- 
nant growths  of,  502,  577;  Maunsell'a 
excision  of,  by  invagination,  571;  the 
fixed,  10;  glands  of,  12;  hemorrhage 
from,  35;  inflammation  in,  cause  of, 
37;  length  of,  9,  10;  linea  dentata  in, 
12;  location  of,  9;  lymphatics  of,  16; 
the  movable,  10;  indications  of  mu- 
cus in,  36;  muscles  of,  16;  myoma  of, 
492;  nayxoma  of,  494;  nerve-ache  of, 
625  (see  also  "Neuralgia");  neural- 
gia of,  306,  625  (see  also  "Neural- 
gia"); nerve-supply  of,  10,  15;  ob- 
struction in,  cause  of,  37;  osteoma 
of,  494;  packing  of,  478;  pain  in,  34; 
papillae  of,  13;  papilloma  of,  488; 
pecten  of,  12;  physiology  of,  29; 
pockets  of,  13;  polyps  of  (see 
"Polyps");  prolapse  of  (see  "Pro- 
lapse"); protrusions  from,  34;  pus  in, 
36;  relations  of,  8;  relation  of  levator 
ani  muscle  to,  17;  relation  of  peri- 
toneum to,  11;  relation  of  skin  dis- 
ease to,  37;  sensation  in,  10;  spina 
bifida  in,  494;  Steinthal's  excision  of, 
by  invagination,  571;  stricture  of  (see 
"Stricture");  structure  of,  9,  10; 
structure  of,  in  infants,  7;  thicken- 
ing of  submucosa  of,  in  inflammatory 
disease  of,  12;  symptoms  of  disturb- 
ance in,  34;  syphilis  of,  feces  in,  72; 
teratoma  of,  491;  tuberculosis  of,  324; 
tumors  in,  36;  ulcer  of  (see  "Ulcer"); 
veins  of,  14. 
imperforate,  classification  of,  74;  diag- 
nosis of,  79;  prognosis  of,  81;  symp- 
toms of,  78;  treatment  of,  83. 

Reduction  oi  prolapse,  391. 

Reflex  disturbances  in  anal  fissure,  302. 

Rehn-Rydygier's  method  for  Kraske  op- 
eration, 549. 

Resection  of  rectum  (see  "Proctectomy"); 
and  anastomosis  in  closure  of  arti- 
ficial anus,  622. 

Respiration,  condition  of,  in  auto-intoxi- 
cation, 126. 

Retractor,  Kelsey's  rectal,  334. 

Rickets's  operation  for  uemorrhoids,  461; 
for  prolapse,  403. 

Rieder,  on  cause,  of  stricture,  350,  353. 

Ringworm,  a  cause  of  pruritus  ani,   ISL 


INDEX 


695 


Rizzoli,  operation  of,  for  congenital  mal- 
formation, 85. 

Roberts's  operation   for  prolapse,   397. 

Robinson,  Byron,  on  membranous  colo- 
proctitis,   218. 

Robson's  method  for   colostomy,   607. 

Roentgen   ray  in  malignant  growths,   537. 

Roux's  modification  of  Kraske  operation, 
549. 

Rugae  of  rectum,  19. 

Rydygier-Rehn  method  for  Kraske  opera- 
tion, 547. 

Sacculations  of  intestine,   4. 

Sacculi  Horneri,  13. 

Sacrum,  anterior,  spina  bifida  of,  494. 

Salmon's  back-cut  in  anal  fistula,   258. 

Salt  solution,  intravenous  injection  of,  in 
hemorrhoids,   481. 

Salts  in  feces,  56. 

Sarcoma,  age-  in,  527;  blood-examination 
in,  532;  cauterization  in,  538;  classi- 
fication of,  505,  521;  Coley's  toxin  in, 
538;  colostomy  for,  539;  complications 
in,  537;  curettage  in,  540;  diagnosis 
of,  529,  531;  divulsion  for,  541;  elec- 
tricity in,  537;  etiology  of,  510;  hem- 
orrhage in,  474;  radical  treatment  of, 
541;  Roentgen  ray  in,  537;  literature 
of,  577;  table  of  location  of,  521; 
lympho-,  523;  melanotic,  523;  metas- 
tasis in,  527;  microscopic  examination 
in,  532;  palliative  treatment  in,  534; 
pathology  of,  521;  proctectomy  for 
(see  "Proctectomy");  proctotomy  for, 
540;  prognosis  of,  533;  surgical  treat- 
ment of,  539;  symptoms  of,  524;  treat- 
ment of,  577. 
differential  diagnosis  of,  from  '  carci- 
noma, 522;  from  fibroma,  522;  from 
hemorrhoids,  426;  from  lipoma,  532; 
from  prolapse,  388;  from  syphilis,  531; 
from  tubercular  deposits,   531. 

Schede's  table  of  operability  in  proctec- 
tomy, 546. 

Schinzinger's  method  of  preventing  fecal 
incontinence   in   colostomy,    611. 

Scissors,  Allingham's,  259. 

Scorbutus,    feces   in,    72. 

Secretion  neurosis.  (See  "Colo-proctitis, 
Membranous.") 

Secretions,  deficiency  of,  a  cause  of  con- 
stipation, 92. 

Sensation,    localization   of,    in   rectum,   15. 

"Sentinel  pile"  in  anal  fissure,  297,  298,  302. 

Sex  in  hemorrhoids,  410. 

Sigmoid,  intussusception  of,  into  rectum, 
387;  invagination  of,  into  rectum,  387; 
prolapse  of,  into  rectum,  387. 

Sigmoidopexy  for  prolapse,  398. 

Sigmoidostomy,  operation  of,  589. 

Sigmoidotomy  in  fecal   impaction,   114. 


Simpson's  operation  of  tenotomy  in  coc- 
cygodynia,   156. 

Sims's  rectal  irrigator  and  drainage-tube, 
336;  position,  48. 

Skin  in  auto-intoxication,  126;  color  of, 
a  symptom  of  rectal  disturbance,  39; 
disease  of,  relation  of,  to  rectum,  37. 

Smegma  bacillus  in  ano-rectal  ulcer,   280. 

Smith's  clamp,   442. 

Snare  for  polyps,  498. 

Sodomy,  653;  disease  caused  by,  187.  (See 
also   "Pederasty.") 

Solution,  Gram's,  for  staining  gonococcus, 
175;  Koch-Ehrlich's  for  staining  gon- 
ococcus, 176;  Ziehl-Neelsen,  for  stain- 
ing tubercle  bacillus,  68;  medicated, 
in  treatment  of  ulcer,  337. 

Spaces,   perirectal,   18. 

Speculum,  use  of,  in  anal  fissure,  304;  in 
examination,  44;  Gant's  operating, 
315;  manipulation  of,  45. 

Sphincter,  dilatation  of,  435;  divulsion  of, 
313,  464;  in  constipation,  95,  96,  102; 
contraction  of,  differential  diagnosis 
of,  from  anal  fissure,  305;  internal, 
12;  of  O'Beirne,  29. 

Sphincteralgia.     (See  "Fissure,  Anal.") 

Spina  bifida  of  rectum,  494. 

Spur,    clamping    of,    in    closing    artificial 
anus,  620;  Gant's  operation  for,  621. 
Allingham's  method   of  forming,   in   co- 
lostomy, 608. 
Bodine's     method     of     forming,     in    co- 
lostomy,  609. 
Kelsey's   method    of    forming,    in    colos- 
tomy,  608. 
Mathews's  method  of  forming,  in  colos- 
tomy,  609. 
Maydl's    method    of    forming,    in    colos- 
tomy,  608. 
Weir's  method  of  forming,  in  colostomy, 
608. 

Staining  of  tubercle  bacilli,  67;  of  gono- 
cocci,  175. 

Stains  lyiii]ilinticus  in  polyps,   485. 

Steinthal's  operation  of  proctectomy  by 
invagination,   571. 

Stenosis,  rectal.     (See  "Stricture.") 

Stick  in  rectum,  illustrative  case,  650. 

Stomach,  hemorrhage  from,  evacuated 
from  rectum,  36. 

Stools,  character  of,  in  stricture,  359. 
(See  also  "Feces.") 

Straining,  a  symptom  of  rectal  disturb- 
ance, 37. 

Strapping  in  prolapse,  392. 

Stricture,  Allingham  on,  352;  annular, 
212,  348;  appearance  of  anus  in,  361; 
a  cause  of  auto-intoxication,  128; 
Bacon's  operation  for,  376;  bandular, 
356;  Bullard,  on  cause  of  non-malig- 
nant,   351,    353;     cause    of,     185,    S51; 


696 


INDEX 


Stricture  (concluded). 

"rectal  valves,"  a  cause  of,  21;  car- 
cinomatous, 518;  colostomy  for,  274, 
378;  after  colostomy,  615;  complica- 
tions of,  361;  congenital,  350;  a  cause 
of  constipation,  92;  Cooper,  on  cause 
of,  350,  351;  Cripps's  table  on,  352; 
diagnosis  of,  362;  diaphragmatic,  356; 
a  cause  of  diarrhea,  141;  differential 
diagnosis  of,  364;  diet  in,  366;  forci- 
ble divulsion  in,  369;  gradual  divul- 
sion  in,  367,  380;  Edwards,  on  cause 
of,  350,  351;  electrolysis  in,  370;  en- 
darteritis as  cause  of,  353;  etiology  of, 
348;  method  of  examination  in,  363 
excision  in,  373;  Gant's  table  on,  352 
gonorrheal,  354;  hemorrhage  in,  474 
illustrative  cases,  377;  literature  of, 
381;  membranous,  356;  mixed  treat- 
ment in,  366;  Nelaton's  operation  in, 
371;  non-malignant,  348;  operative 
treatment  in,  367;  non-operative  treat- 
ment of,  366;  pathology  of,  349,  357; 
peritonitis  in,  360;  phantom,  356;  press- 
ure causing,  357;  proctitis  in,  354; 
proctoplasty  in,  375;  external  proc- 
totomy in,  371,  380;  internal  proctot- 
omy in,  377;  posterior  proctotomy  in, 
371,  377;  after  proctectomy,  574;  prog- 
nosis of,  365;  Rieder,  on  cause  of, 
350,  353;  spasmodic,  356;  character  of 
stools  in,  359;  symptoms  of,  358; 
syphilitic,  350,  351;  traumatic,  351; 
treatment  of,  145;  tuoercular,  212,  348, 
355;  varicose  ulcers  in,  356;  "rectal 
valves"  in,  356;  valvular,  356;  vene- 
real, 351. 

Strychnine,  injection  of,  in  treatment  of 
prolapse,  392. 

Stubbert,  on  relation  of  pulmonary  tuber- 
culosis to  anal  fissure,   275. 

Styptics  in  hemorrhage,   480. 

Submucous    ligation    in    hemorrhoids,    461. 

Succussion  in  examination,  51. 

Symmetric  abscess,  227. 

Syphilis,  anal  fissure  in,  303,  304;  of  coc- 
cyx, 166;  congenital,  181;  differential 
diagnosis  from  carcinoma,  531;  feces 
in,  72;  illustrative  case,  187;  litera- 
ture of,  188;  manifestations  of,  179; 
secondary,  180;  as  cause  of  stricture, 
350;  symptoms  of,  180,  181;  treatment 
of,  180,  181;  as  cause  of  ano-rectal 
ulcer,  320. 

Syphiloma,  ano-rectal.    (See  "Gummata.") 

Syringe,  Gant's  injecting,  458;  Gant's 
recto-colonic  ointment,  337. 

System,  circulatory,  condition  of,  m  auto- 
intoxication, 125;  nervous,  condition 
of,  in  auto-intoxication,  126;  respira- 
tory, condition  of,  in  auto-intoxica- 
ticn.   126. 


Xable,  examining,  42;  Allison's,  43. 

Taxis  in  reduction  of  prolapse,  391. 

Tenia  in  chronic  diarrhea,  60. 

Tenotomy,  subcutaneous,  of  levator  ani  in 
constipation,  102. 

Teratoma   of   rectum,   491. 

Theory,  Cohnheim's,  for  carcinoma,  509; 
heredity,  for  carcinoma,  509;  parasite, 
for  carcinoma,  507;  traumatic,  for 
carcinoma,   507. 

Thomas's   curved   tissue-forceps,    445. 

Threadworms  in  anal  fistula,  312. 

Torsion  in  hemorrhage,   480. 

Toxemia  in  rectal  disease,  38;  fecal,  110. 
(See    also    "Auto-intoxication.") 

Traumatic  theory  for  carcinoma,  508. 

Traumatism,   hemorrhage  from,   474. 

Treves's  operation  for  prolapse,   402. 

Truss,   hemorrhoidal,  433. 

Trusses  in  treatment  of  prolapse,  392. 

Tube,  Sims's  drainage,  and  rectal  irri- 
gator, 331. 

Tubercle  bacillus  in  feces,  60,  67;  exami- 
nation of,  68;   staining  of,  68. 

Tuberculosis,  bacillus  of,  in  feces,  60,  67; 
of  coccyx,  166;  of  intestine,  feces  in, 
67;  differential  diagnosis  from  sar- 
coma, 351;  a  cause  of  stricture,  356; 
pulmonary,  relation  of,  to  anal  fist- 
ula, 275;  rectal,  324;  verrucosa,  326. 

Tumors,  non-malignant  (see  "Polyps"); 
malignant,  502;  rectal,  36;  sacro-coc- 
cygeal,  161;  literature  of  sacro-coc- 
cygeal,  173. 

Tuttle's  operation   for   anal   fistula,   266. 

Tympanites  in  rectal  disturbance,  38. 

Typhoid  fever,  bacillus  of,  in  feces,  60, 
70;  feces  in,  70;  hemorrhage  in,  70. 

yicer  as  cause  of  constipation,  92;  as 
cause  of  diarrhea,  65;  blood  in  feces 
in,  65;  differential  diagnosis  from 
anal  fissure,  303;  gonorrheal,  323; 
hemorrhage  in,  472;  hemorrhoidal, 
330;  irritation  from,  transferred  to 
other  parts,  15;  irritable  (see  "Fis- 
sure, Anal");  painful  (see  "Fissure, 
Anal");  in  rectal  disturbance,  15,  38, 
92;  rodent,  differential  diagnosis  from 
esthiomene,  342;  symptom  of  consti- 
pation, 93;  traumatic,  etiology  and 
pathology  of,  319;  treatment  of,  146. 

catarrhal,  etiology  of,  324;  p-^thology  of, 
324;  varieties  of,  324. 

chancroidal,  etiology  of,  323;  diagnosis 
of,   334. 

dysentery,  etiology  of,  327;  pathology  of, 
327;  prognosis  of,  334;  treatment  of, 
335;  Ziegler  on,  327. 

intestinal,  blood  in  feces  in,  65;  char- 
acter of  feces  in,  65;  pus  in  feces  in, 
65. 


INDEX 


697 


Ulcer  (concluded), 
malignant,    diagnosis   of,    334;    prognosis 

of,  334. 
non-malignant,  actinomycosis  as  cause 
of,  331;  bartholinitis  as  cause  of,  330; 
catarrhal,  324;  cauterization  in,  337; 
in  children,  319;  classification  of,  319; 
colostomy  in,  338;  curetting  in,  338; 
diagnosis  of,  334;  diarrhea  in,  331; 
diet  in,  336;  discharges  in,  333;  di- 
vulsion  in,  338;  dusting-powders  in, 
337;  dysenteric,  327;  etiology  of,  319; 
excision  in,  338;  hemorrhage  in,  332; 
illustrative  cases,  343;  incision  in, 
338;  injections  in,  337;  itching  in,  333; 
leprosy  as  cause  of,  331;  literature  of, 
346;  local  applications  in,  336;  pain  in, 
332;  non-operative  treatment  of,  335; 
pathology  of,  319;  prognosis  of,  334; 
rest  in,  336;  -  solutions  in,  337;  sur- 
gical treatment  in,  338;  symptoms  of, 
331;  traumatic,  318;  varieties  of,  319; 
varicose,  329;  venereal,  320. 
syphilitic,   diagnosis  of,  334;   etiology  of, 

321;  pathology  of,  321. 
tubercular,  diagnosis  of,  334;  etiology 
of,  324;  illustrative  cases,  345;  pa- 
thology of,  324;  prognosis  of,  334; 
varieties  of,  325. 
varicose,  a  cause  of  stricture,  356;  eti- 
ology of,  329;  pathology  of,  329. 

•  venereal,  etiology  of,  320;  pathology  of, 
320;  prognosis  of,  334;  treatment  of, 
335. 

Ulceration,  non-malignant  (see  "Ulcer, 
Non-malignant");   pin-point,  212. 

Urbane's  operation   for  prolapse,  394. 

Urinary  calculi   in  rectum,  639. 

Urination,  relation  of  levator  anl  muscle 
to,  17. 

Urine,  examination  of,  51;  indican  in, 
125;  in  malignant  growths,  532. 

Va&inal  proctectomy,  operation  of,  565; 
Bdebohls's  operation  of,  572. 

Valve,  ileo-cecal,  anatomy  of,  3;  semi- 
lunar,  13;   in  fissure  in  ano,   297,   298. 

"Valves,"  Houston's,  10,  12;  history  of, 
19.  (See  also  '"Valves,  Rectal.'") 
rectal,  arrangement  of,  20;  as  cause  of 
constipation,  90;  as  cause  of  fecal 
impaction,  108;  as  cause  of  stricture, 
21,  356;  forms  of  obstruction  of,  24; 
function  of,  20,  23,  24,  26;  history  of, 
19,  20;  hyperplasia  of,  24;  location  of, 
23,  25,  27;  in  membranous  colo-proc- 
titis,  219;  number  of,  23,  27;  Penning- 
ton on,  24;  structure  of,  20,  27,  28. 

"Valvotomy,"  advantages  of  the  clamp 
operation  in,  105;  in  constipation,  103; 
disadvantages  of  cutting  operation 
for,    106;     Gant's    operation    of,     104; 


Martin  s  operation  of,  105;  the  opera- 
tion of,  104. 

Van  Buren,  opinion  of,  on  "rectal  valves," 
22;  operation  for  prolapse,  394. 

Varicose  ulcer,  3i;j;  a  cause  of  stricture, 
356. 

Vegetation,  venereal.     (See  "Condyloma.") 

Vein,  portal,  feces  in  congestion  of,  72; 
of  rectum,   14. 

Velpeau,  opinion  of,  on  "rectal  valves," 
21. 

Venereal  warts,  differential  diagnosis 
from   hemorrhoids,    i27. 

Ventral  fixation  for  prolapse,  398. 

Verneuil's   operation   for   prolapse,    397. 

Vesical  disturbance  following  proctec- 
tomy, 574. 

Vogel's  table  of  mortality  in  proctectomy, 
564. 

Vomiting,   fecal,   32. 

Vulva,  elephantiasis  of,  494. 

'\Yales's  bougies,  soft  rubber,  372;  in 
divulsion  of  the  sphincter,  96. 

Walker's  method  of  performing  Kraske's 
operation,  549. 

Warts,  venereal  (see  "Condyloma");  dif- 
ferential diagnosis  from  hemorrhoids, 
427. 

Water  in  the  treatment  of  constipation, 
100;  in  treatment  of  hemorrhage,  480. 

Weight,  loss  of,  a  symptom  of  rectal  dis- 
ease, 39. 

Weir,  Dr.  R.  F.,  method  of  forming  spur 
in  colostomy,  608;  of  preventing  fecal 
incontinence  in  colostomy,  611. 

Welch,  Dr.  W.  H.,  on  bacillus  coli  com- 
munis, 130,  135. 

Whitehead  dilator,  370;  operation  of,  for 
hemorrhoids,  449;  disadvantages  of 
operation  of,  453. 

Willems's  method  of  performing  Kraske's 
operation,    551. 

Wire  in  the  operation  of  prolapse,  394. 

Witzel's  method  of  preventing  fecal  in- 
continence in  colostomy,   612. 

Wolfler's  method  of  performing  Kraske's 
operation,   549. 

Worms  in  anal  fissure,  312;  in  chronic 
diarrhea,  60;  in  feces,  58. 

Wounds  of  rectum,  647;  literature  of,  652; 
symptoms  of,  649;  treatment  of,  650. 

Wyeth's  method  of  preventing  fecal  in- 
continence in  colostomy,  613. 

X-ray  in  malignant  growths,  537. 

Yeast  in  feces,  56. 

Ziegler,  on  dysenteric  ulcer,  327. 

Ziehl-Neelsen  solution  for  staining  tuber- 
cle bacilli,   68. 

Zuckerkandl,  method  of  performing 
Kraske's  operation. 


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